social and emotional wellbeing service experiences of
TRANSCRIPT
1
Social and Emotional Wellbeing service experiences of Aboriginal young people in New South Wales,
Australia: listening to voices, respecting experiences, improving outcomes.
Jasper Jerome Garay
A thesis submitted in fulfillment of the requirements for the degree of Master of Philosophy
Sydney School of Public Health Faculty of Medicine and Health
The University of Sydney
26/11/2020
2
Statement of originality
This is to certify that to the best of my knowledge, the content of this thesis is my own work.
This thesis has not been submitted for any degree or other purposes.
I certify that the intellectual content of this thesis is the product of my own work and that all
the assistance received in preparing this thesis and sources have been acknowledged.
Signature:
[removed on this copy]
Name: Jasper Jerome Garay
3
Abstract
Many Aboriginal and Torres Strait Islander young people in New South Wales have lived
experiences of mental health/social and emotional wellbeing services and systems. These
lived experiences and knowledges are of great value to services and systems that are
seeking to improve mental health/social and emotional wellbeing health outcomes through
systemic reform. The lived experiences of Aboriginal and Torres Strait Islander young people
are crucial to developing an authentic understanding of why some services and systems
work and why some services and systems do not work; they also offer a consumer
perspective on how mental health/social and emotional wellbeing services and systems
could be improved.
While there is a growing body of research providing evidence suggesting that young
Aboriginal and Torres Strait Islander peoples experience very high burdens of mental
health/social and emotional wellbeing challenges, there is minimal research on mental
health/social and emotional wellbeing help-seeking, service experiences or on what works
(and why or why not). This research fills part of that knowledge gap.
This research forms part of a larger body of work being undertaken by the Study of
Environment on Aboriginal Resilience and Child Health (SEARCH) team in partnership with
several Aboriginal Community Controlled Health Services (ACCHS) in New South Wales,
Australia. It aims to privilege the voices, experiences, and perspectives of Aboriginal and
Torres Strait Islander young people who use mental health/social and emotional wellbeing
services and systems in New South Wales. Through this data the research aims to establish a
consumer perspective on how current mental health/social and emotional wellbeing
services and systems can build upon current strengths and successes. It also aims to preview
4
suggestions for change by positioning the voices of Aboriginal and Torres Strait Islander
young people as experts on their own needs.
Aboriginal young people involved in this study did have suggestions for reforms to
Social and Emotional Wellbeing services that would improve outcomes across five key
themes: access, cultural appropriateness, early intervention, service integration, and
effectiveness. Overall, enhanced accessibility to holistic Social and Emotional Wellbeing
services that genuinely support clients in their wellbeing journeys was identified as
needed. Earlier intervention services were identified as important and requiring further
embedment in communities, with services that do exist suggested to better utilise
culturally informed and person-centered approaches to care.
This thesis presents a synthesis of related literature, mental health/social and emotional
wellbeing data and policies and uses qualitative health research methods to position the
voices, experiences, and perspectives of current Aboriginal and Torres Strait Islander young
people as experts in this research.
5
Acknowledgements
To live on these lands and be nurtured by our waters is my biggest blessing. I’m proud to
have family from Darkinjung and Ngarigo countries in New South Wales. Born on
Cammeryagal lands and currently living on Gadigal lands, I have been fortunate enough to
visit many other Countries1 too. East coast sea water, southern snowy mountains, endless
bush, north western red desert dirt, freshwater rivers, sub-tropics. Awe is never ceded when
I’m with nature where we live. Respect must always be given first to this, as these surrounds
innately help to shape who I am, why I’m here, and allow us all to exist.
When you really appreciate our historical timelines, ‘generations’ seems inconsiderate when
attempting to acknowledge those who cared for where I now live before my time.
Acknowledgments secondly must always be to these many peoples. Elders, leaders, and
those who grew under the ways that remain our cultural strengths, I hope this work does
justice for how you’ve enabled us to live today. I acknowledge much work remains to be
done yet also acknowledge that we have come a long way because of your lives.
Thank you to all the Aboriginal young people who let me listen to your experiences. Not one
time did I journey home and not appreciate how brave it was to so openly share information
that could maybe help change others around you. Even when this thesis is done, I’ll keep
working hard to make sure that change does happen, I appreciate you being involved in the
beginning of my journey to help. All the information that follows encourages your voices to
keep being heard, so please keep talking, knowing that we are who cares next for what we
have.
1 Countries is used here to refer to the many Australian Aboriginal and Torres Strait Islander lands (Countries) I have visited.
6
Aboriginal Medical Services, Aboriginal Health Workers, Aboriginal community members,
are the backbone of this research. Without these people, none of this would be achievable.
Thank you for your time and sharing your wisdom. These peoples know best, they know
what they need, and we need to continue working to best help achieve these changes.
SEARCH and the Sax Institute have allowed me to work alongside amazing people in an
organisation that does things for the right reason and in the right ways. Pete, Janice,
Mandy, Simone, Anna, Christian, Sumi, Deanna, I appreciate feeling part of it all from the
start. Thanks for all you’ve done for me, it’s a pleasure to say I work with you.
Joel, Kirsten and the Sydney School of Public Health have been major supports in achieving
completion of this thesis. Everything has always seemed worthwhile over the past two
years; I’m surrounded by such great and progressive people that, without doubt, influenced
me to be consistently better. Thanks particularly to my GDIHP team, for in this community
you are my day to day and biggest supports above all.
Ms Berger, thanks for telling me I can do more than tackle people for a living one day. Mr
Barris, thanks for telling me I could write well and should study more after our time spent
learning in legal studies. Mr Hayman and Mr Aldous, thanks for involving me in our teams
and helping me understand the importance of playing my role, it taught me success needs
work ethic.
Garay and Dickson families, I love you all. Who would have thought I’d be writing an
acknowledgment section to thank you, as the first ever male to graduate with a
postgraduate degree? But here I am. It’s humbling, and it feels good too. Younger ones, I
wish that you keep working hard, being kind, and feel like this at least once. Elders, I’m
grateful for being shown the importance of always maintaining these qualities, thank you.
7
Valerie, thank you for listening. I’m looking forward to talking about everything and
anything but my thesis very soon. Many times, your interest in my work reignited my
passion during times it was missing. I’ll always love you for that.
Thank you for reading my thesis. Overall, I simply hope it helps contribute to making positive
changes for a better future.
8
Contents Statement of originality .......................................................................................................................... 2
Abstract ................................................................................................................................................... 3
Acknowledgements ................................................................................................................................. 5
Chapter 1: Introduction ........................................................................................................................ 12
1.1 My research question ..................................................................................................................... 12
1.2 My Masters and Me: Why are you reading this? ............................................................................ 12
1.3 How this thesis is structured ........................................................................................................... 17
Chapter 2: Background and context ..................................................................................................... 20
2.1 Aboriginal and Torres Strait Islander peoples in Australia .............................................................. 20
2.1.1 Our current population ................................................................................................................ 21
2.2 Defining Social and Emotional Wellbeing (SEWB) in this research ................................................. 21
2.2.1 Social and emotional wellbeing transcends Western views of mental health ............................ 22
2.2.2 Social and emotional wellbeing involves an individual, their family and community ................. 22
2.2.3 Aboriginal and Torres Strait Islander cultural values as guiding principles of understanding social and emotional wellbeing ............................................................................................................. 23
2.3 Social and Emotional Wellbeing and mental health in Australia – what do we know? .................. 26
2.3.1 What do we know about Aboriginal and Torres Strait Islander Peoples’ and social and emotional wellbeing? ............................................................................................................................ 27
2.3.2 Our Aboriginal and Torres Strait Islander population is younger and is experiencing life stressors and psychological distress early ............................................................................................ 28
2.3.3 The social determinants of health and social and emotional wellbeing ...................................... 29
2.3.4 The impact of the diversity of contemporary Australia on the social and emotional wellbeing of young people ........................................................................................................................................ 30
2.3.5 Being young and Aboriginal and Torres Strait Islander in contemporary Australia can be complex ................................................................................................................................................. 31
2.4 Aboriginal and Torres Strait Islander young people- the deficit discourse ..................................... 32
2.4.1 Shifting the deficit discourse and engaging with strengths ......................................................... 33
Chapter 3: The Social and Emotional Wellbeing Policy context............................................................ 35
3.1 Introduction to this chapter ............................................................................................................ 35
3.2 Seminal policy work in Aboriginal and Torres Strait islander health and social and emotional wellbeing ............................................................................................................................................... 36
3.3 The First National Mental Health strategy 1992 – 2003 ................................................................. 37
3.4 The Second National Mental Health Plan 1998 – 2003 ................................................................... 40
3.5 The Third National Mental Health Plan 2003 – 2008 & The National Strategic Framework for Aboriginal and Torres Strait Islander People’s Mental Health and Social and Emotional Wellbeing 2004-2009 ............................................................................................................................................. 44
3.6 The Fourth National Mental Health Plan 2009 – 2014 ................................................................... 47
9
3.7 The Fifth National Mental Health Plan 2017-2022 ......................................................................... 50
3.8 The National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2017 – 2023 .................................................................... 53
3.9 Chapter summary............................................................................................................................ 54
Chapter 4: Methodology and Methods ................................................................................................ 56
4.1 Introduction .................................................................................................................................... 56
4.2 Research ‘with’ not ‘on’ Aboriginal and Torres Strait Islander peoples and communities ............. 56
4.3 The SEARCH Study ........................................................................................................................... 57
4.3.1 The contributions of this thesis to the broader SEARCH study .................................................... 58
4.4 Research design .............................................................................................................................. 60
4.4.1 Ethics approvals ........................................................................................................................... 60
4.4.2 Recruitment and participants ...................................................................................................... 61
4.4.3 Participant Welfare ...................................................................................................................... 62
4.4.4 Data collection ............................................................................................................................. 63
4.4.5 Analysis ........................................................................................................................................ 64
Chapter 5: Results ................................................................................................................................. 65
5.1 Introduction .................................................................................................................................... 65
5.2 : Theme 1- Knowing what SEWB services exist and early intervention ........................................... 65
5.2.1 ACCHSs primary providers of SEWB care ..................................................................................... 66
5.2.2 Challenges in knowing how to get SEWB support and services ................................................... 66
5.2.3 A need for more information about options for SEWB support .................................................. 68
5.2.4 A need for information to help understand what SEWB support is like ...................................... 68
5.2.5 Schools and education-based programs as key opportunities for early intervention ................. 69
5.2.6 Outreach services considered to be effective .............................................................................. 70
5.3 : Theme 2- Accessing SEWB services ............................................................................................... 71
5.3.1 Aboriginal Community Controlled Health Services (ACCHSs) ...................................................... 71
5.3.2 Approachability and flexibility of ACCHSs .................................................................................... 71
5.3.3 Outreach services from the ACCHSs ............................................................................................ 72
5.3.4 Shortfalls in using ACCHS SEWB services ..................................................................................... 72
5.3.5 Mainstream system SEWB services ............................................................................................. 73
5.3.6 An absence of alternative options for SEWB care ....................................................................... 74
5.3.7 Person-centered care is what we want ........................................................................................ 75
5.3.8 Holistic services are desired ......................................................................................................... 76
5.3.9 The Emergency Department (ED) needs to change, it’s a crisis driven system ........................... 77
5.3.10 Inadequate SEWB and mental health assessment in the emergency department ................... 78
5.3.11 Being taken seriously in the Emergency Department ................................................................ 79
10
5.3.12 More SEWB and mental health supports are needed in the emergency department .............. 80
5.4 : Theme 3- Cultural Safety and SEWB services................................................................................. 81
5.4.1 Culturally relevant SEWB care...................................................................................................... 81
5.4.2 ACCHS = Culturally appropriate SEWB services ........................................................................... 82
5.4.3 Mainstream SEWB system & services – insufficient for Aboriginal needs, failing to cater for Aboriginal cultural safety ...................................................................................................................... 82
5.5 : Theme 4- Service Integration ......................................................................................................... 85
5.5.1 SEWB services and systems need to work together .................................................................... 85
5.5.2 ACCHS make efforts to enhance SEWB service integration for clients ........................................ 86
5.6 Chapter summary............................................................................................................................ 87
Chapter 6: Discussion and conclusion ................................................................................................... 88
6.1 Introduction .................................................................................................................................... 88
6.2 Building on the Mental Health and Social and Emotional Wellbeing Framework .......................... 89
6.3 Shifting the deficit discourse and engaging with strengths ............................................................ 92
6.4 : Opportunity 1 – Firmly ground Social and Emotional Wellbeing Services in culture .................... 93
6.4.1 Strategic action (i) Engage Culture, spirit and spirituality ............................................................ 94
6.4.2 Strategic action (ii) Engage ongoing connections to Country ...................................................... 96
6.4.3 Strategic action (iii) Engage family and community level support networks ............................... 97
6.4.4 Strategic action (iv) Keep building up Aboriginal Community Controlled Health Services .......... 98
6.4.5 Strategic action (v): More Aboriginal and Torres Strait Islander staff in SEWB services ............. 99
6.5 : Opportunity 2 - Take time, see us, listen to us- simple consumer-centered SEWB services ....... 100
6.5.1 Strategic action (i): Human to human interaction in SEWB service delivery ............................. 100
6.5.2 Strategic action (ii)- Use clear communication .......................................................................... 101
6.6 : Opportunity 3 - Services working together, are better services .................................................. 102
6.6.1 Strategic action (i) Services should share after care and follow ups ......................................... 102
6.6.2 Strategic action (ii) – Make better use of Aboriginal health workers or navigators .................. 103
6.6.3 Strategic action (iii) : SEWB services and schools need to work together ................................. 103
6.7 : Opportunity 4 - Stop young Aboriginal people from “falling through the cracks” ...................... 104
6.7.1 Strategic action (i) – screen early and do early intervention for SEWB needs ........................... 104
6.7.2 Strategic action (ii) Slow down the time taken for doing an assessment .................................. 104
6.7.3 Strategic action (iii) – Decrease barriers to accessing SEWB services ........................................ 105
6.7.4 Strategic action (iv) change SEWB processes in the EDs ............................................................ 106
6.8 Strengths of this research ............................................................................................................. 107
6.9 Limitations of this research and ideas for future research ........................................................... 107
6.10 Conclusion ................................................................................................................................... 108
Appendix 1: Sample yarning interview guide...................................................................................... 112
11
Appendix 2: Examples of ongoing engagement, research progress updates and communication with SEARCH Study ACCHS .......................................................................................................................... 113
Appendix 3: ACCHS CE/ Directors final sign off and approval for this thesis submission ................... 114
References .......................................................................................................................................... 115
12
Chapter 1: Introduction
1.1 My research question
Through this research I explored how a group of Aboriginal and Torres Strait Islander1 young
people2 experienced social and emotional wellbeing (SEWB)3 services in New South Wales
(NSW), Australia. SEWB services include any mental health and emergency department
services that have been accessed by Aboriginal young people in their respective Local
Health District to assist with achieving better individual SEWB. I wanted to use a research
methodology and methods that would support the participation of young people in
research, to authentically listen to their experiences with the SEWB system in NSW. I
wanted to research their lived experiences of SEWB services through research that
respectfully valued their voices.
My hope is that this research contributes to developing a better understanding of the SEWB
services accessed by this group of young Aboriginal and Torres Strait Islander peoples and
that a more in-depth understanding of their lived experiences contributes to making
changes to the SEWB system that lead to improvements in health and wellbeing outcomes
for Aboriginal and Torres Strait Islander young peoples in NSW.
1.2 My Masters and Me: Why are you reading this? I think the position of Aboriginal and Torres Strait Islander young people in Australia is an
interesting topic. Health and education, both pillars of my profession as an academic in
Indigenous Health Promotion, have always been components of Aboriginal and Torres Strait
1 Aboriginal and Torres Strait Islander peoples are the first peoples of Australia. They are the original custodians of Australia and have cared for Country for generations. 2 This research defines young peoples as 16 to 24 years of age 3 I use the term social and emotional wellbeing (SEWB), rather than mental health, throughout this thesis. A description of the term, and rationale for the use, is provided later in the thesis.
13
Islander young people’s SEWB that for me, are difficult not to dwell on when compared to
others.
Often when I speak of my research and work in the School of Public Health to friends or
those just acquainted, fascination and surprise exist amongst the myriad of responses
received. Colleagues, whether at The University of Sydney or external, have always given
genuine interest and supportive willingness to assist my work in Aboriginal and Torres Strait
Islander health and education. Much good is being done in this space, and I feel this should
not be underestimated. Future generations of Aboriginal and Torres Strait Islander young
people will continue to be happier and healthier, and despite what the lay person may be
misled to believe, this is the truth. I have always wanted to find ways of contributing to this
ongoing process of progress. Hopefully when reading this thesis, you will be able to feel that
this has been my biggest effort to date.
Community is important for Aboriginal and Torres Strait Islander people. I’m lucky as a
younger Koori4 academic to have a collective and supportive network of friends, colleagues,
partners, students, and communities whose lives respect that Aboriginal and Torres Strait
Islander culture and ways of being, knowing, and doing come first in our nation’s many
Countries (Martin & Mirraboopa, 2003). Being the individual who has for the past two years
committed to fulfilling the institutional requirements of thesis completion, I do have some
reasons of personal committal to research involving Aboriginal and Torres Strait Islander
young people and SEWB worthy of mention.
4 Koori is a word often used when referring to an Aboriginal person from NSW.
14
ACCHS are community driven, culturally safe, unique models of health and wellbeing service
provision. Attaching health and wellbeing to community connectedness, ACCHS do more
than function as a medical organisation. Rather, cultural leadership, role modelling,
Aboriginal and Torres Strait Islander governance, business, and partnerships for health,
along with many others, are central features of an ACCHS. All these qualities are invaluable
in embedding meaningful community health structures. It was a privilege to work alongside
the guidance and wisdom from all those involved in helping with my first research project. I
appreciate that this was just a small part of the day to day commitments that these health
workers and services make to improve community SEWB. Thank you for letting me be
involved with this work. The opportunity to work with these communities was one major
personal reason I felt this thesis should be written. I hope I have helped contribute to the
body of evidence that proves how ACCHS require greater recognition and support in our
state’s (NSW) health sector.
Aboriginal and Torres Strait Islander young people have voices that are not being listened
to. They have experienced growing up in a way distinctive to many other Australians. Having
opinions of our colonial society that intertwine modern complexities with subjective cultural
attachments to the true traditional histories of Australia is something we should see as
unique and valuable, not avoid.
Aboriginal and Torres Strait Islander young people do want to be heard. Heard about in
what ways the world they live in is being good to them, about how it is not, and about how
they would make changes for the better if it were possible. Maybe this thesis did not
achieve this level of qualitative depth, yet I do know that it is a start. If our world of research
15
continues to neglect Aboriginal and Torres Strait Islander young people’s voices, failure to
make positive changes will persist, even when good is being achieved.
In Australia, not many have asked Aboriginal and Torres Strait Islander young people aged
16 to 24 about SEWB experiences of services. Very few have even engaged in qualitative
health research of any sort with Aboriginal and Torres Strait Islander young people. My view
is that SEWB is intrinsically and holistically connected to good outcomes in health and
education. This thesis became an opportunity whereby way of help, I could be someone
listening to voices and promoting change in accordance with what was heard and desired.
Engaging in research directed by two ACCHS respects proper ways of achieving outcomes
for community through research. SEARCH, as research partners, provided the framework for
which we could do so, and writing this thesis allowed Aboriginal and Torres Strait Islander
young people’s voices to have a platform to be heard.
More than ever, opportunities exist for Aboriginal and Torres Strait Islander young people to
be supported to do well. SEWB services for Aboriginal and Torres Strait Islander young
people is not an area that is successfully supportive. I hope that through action of
conducting this research and completing this thesis, our efforts can become an example that
respectfully represent how Aboriginal and Torres Strait Islander young people’s voices can
be delivered as evidence to a wider audience who unlike themselves, are currently in
positions to generate meaningful change for the better.
Experiences, opinions, and suggestions all shared during the evaluation of personal SEWB
service experiences provides extremely promising commitment from Aboriginal and Torres
Strait Islander young people to improving community level health through engagement with
16
qualitative research. Our academic communities increasingly are exposed and involved in
Aboriginal and Torres Strait Islander health research and education. As a younger Koori man,
it was of major shock that so many gaps existed in research pertaining to SEWB and
Aboriginal and Torres Strait Islander young people. Health and education have always
dominated the Aboriginal and Torres Strait Islander discourse academically and socially. And
despite the devastating discrepancies across suicide mortality, juvenile incarceration, social
determinant measures, and social capital, SEWB has only recently become identified as a
priority for Aboriginal and Torres Strait Islander young people.
So why then, in 2020, at twenty-five years of age, am I discovering that Aboriginal and
Torres Strait Islander young people still remain on the fringe of SEWB research?
Having worked on this project for two years now, I appreciate how complex health research
can be. Whichever approach you take however, research on SEWB and Aboriginal and
Torres Strait Islander young people will uncover intersections with inequalities whose
differences to other young Australians are frankly unsettling. Unsettling perhaps the most, is
that I continue to become aware that very few researchers have inquired qualitatively about
these differences or invested in any form of endless research opportunities involving SEWB
and Aboriginal and Torres Strait Islander young people whatsoever.
You are reading this because as a Koori man with a position in a Western institution, that
comes with a platform in academia that can generate changes in a Western society, I felt I
could not sit back and persistently be upset with our Aboriginal and Torres Strait Islander
young peoples’ SEWB status.
17
This thesis was undertaken to overall act as a vehicle to transport Aboriginal and Torres
Strait Islander young people’s voices to those that can help with what they need changed
for the better. If you are reading this, I simply hope that you too will find a way to make
your own contribution to change in this area, as without positive SEWB growing up
Aboriginal and Torres Strait Islander, our future generations will encounter the same fate as
those before them.
1.3 How this thesis is structured
An important thread that is woven throughout this thesis, and holds the main argument
together, is the importance of listening and engaging with the voices of young Aboriginal
and Torres Strait Islander peoples, as users of the SEWB system and experts in their own
lived experiences. I argue that SEWB systems and services could be vastly improved by
valuing those lived experiences and voices; they do not only highlight what is working (and
why) but also contribute practical strategies that have transformative potential for SEWB
policy, services and systems. My thesis structure provides important context, builds theory,
outlines methodology and methods, and provides an analysis of how young Aboriginal and
Torres Strait Islander peoples experience SEWB services in several locations across New
South Wales. Additionally, it synthesises and presents strategic suggestions for innovative
change to SEWB services for young Aboriginal and Torres Strait Islander peoples.
In Chapter one I present my research question and position myself within the research as a
young Koori person and a young Koori researcher. I describe some cultural context and
establish my commitment to ensuring my research privileges young Aboriginal and Torres
Strait Islander peoples’ voices and their lived experiences with SEWB systems and services.
18
Chapter two provides important background and context for this research. It explores issues
pertaining to Western and Aboriginal and Torres Strait Islander understandings of health
and wellbeing, of mental health and social and emotional wellbeing. A synthesis of literature
provides key knowledge related to young Aboriginal and Torres Strait Islander peoples and
their social and emotional wellbeing.
In chapter three I provide an overview of key policy developments in Aboriginal and Torres
Strait Islander health and wellbeing. Importantly, I explore the policy context for any specific
focus on Aboriginal and Torres Strait Islander young peoples. The chapter strongly supports
the need to reorient SEWB health services towards reform that utilises and includes
Aboriginal and Torres Strait Islander young people’s voices, perspectives, and lived SEWB
experiences.
I provide details about my methodology and methods in chapter 4. As such I position my
thesis as part of a larger body of work being undertaken within the SEARCH study. As a Koori
researcher I focus on the importance of building relationships in research, upon engaging to
create safe and welcoming research spaces and upon the use of yarning as a research
method.
My research findings are presented in chapter 5. I identify four main themes from the data
collection from yarning interviews with Aboriginal and Torres Strait Islander young people.
Each main theme has several sub themes that further add insight into the overarching main
themes.
Chapter six brings together findings from the yarning interviews with young Aboriginal and
Torres Strait Islander peoples and positions them within a strengths-based narrative. This
19
chapter is written to overturn the overused deficit model that often is used to describe
Aboriginal and Torres Strait Islander health and wellbeing, or issues in general. Continuing to
learn from the expert lived SEWB experiences of the young Aboriginal and Torres Strait
Islander participants, I propose several opportunities for SEWB policy makers, systems, and
services to consider. Key strategies are suggested underneath each identified opportunity,
providing scope for transformative change in SEWB services for Aboriginal and Torres Strait
Islander young peoples.
20
Chapter 2: Background and context
2.1 Aboriginal and Torres Strait Islander peoples in Australia
Aboriginal and Torres Strait Islander peoples (who I identify with, culturally) have occupied
Australia, our traditional lands, for 50,000 to 100,000 years (Dudgeon, Milroy & Walker,
2014). Integral to our culture is our caring for Country5, a way of living that connects us to
our Lands in ways that ensure sustainability of place and of peoples. Our caring for, and
connection to Country, allows us to maintain all parts of our life that ultimately impacts our
health and wellbeing.
The British invasion of Country over 200 years ago led to our Country being labelled Terra
Nullius, a Latin term translating to a land that belongs to nobody. Aboriginal and Torres
Strait Islander sovereignty was not recognised at that point in the history of Australia and
with this lack of recognition came racism, discrimination, laws that allowed the forced
removal of children from their family and community, a loss of language, cultural ways, and
identity. The invasion and loss of Country led to generations of dispossession and
oppression that allowed for abuse of basic human rights that negatively impacted on
connections to Country, health and wellbeing, creating health and wellbeing inequities that
remain to date (Dudgeon et al., 2014).
5 Being connected to Country describes Aboriginal and Torres Strait Islander peoples’ relationships with cultural land, called Country.
21
2.1.1 Our current population
In 2019 the Australian Bureau of Statistics estimated the Aboriginal and Torres Strait
Islander population of Australia to be 847,190, or 3.3% of Australia’s total population
(Australian Bureau of Statistics (ABS), 2019), with NSW having the highest Aboriginal and
Torres Strait Islander population (281,107 people) (ABS, 2019). More than one-third (37%)
of Aboriginal and Torres Strait Islander peoples lived in major cities (Australian Bureau of
Statistics (ABS), 2017), with 32% of the total Aboriginal and Torres Strait Islander population
living across three regions in eastern Australia (NSW Central and North Coast, Brisbane and
Sydney-Wollongong) (ABS, 2017). The dominance of high urban populations is relevant to
this research, as it is located in urban settings in NSW. Also significant to this research is the
fact that the Aboriginal and Torres Strait Islander population is greatly younger than the
non-Indigenous population of Australia, with one third (33%) of Aboriginal and Torres Strait
Islander peoples aged less than 15 years, compared with 18% of their non-Indigenous
counterparts. Fifty-three per cent of the Aboriginal and Torres Strait Islander population
was aged between 0 to 25 years, with 19% of the total Aboriginal and Torres Strait Islander
population aligning with the age cohort for this study involving Aboriginal young people
aged 16 to 24 years of age (ABS, 2017) .
2.2 Defining Social and Emotional Wellbeing (SEWB) in this research
Social and emotional wellbeing (SEWB) is a term that defines an Aboriginal and Torres Strait
Islander concept of physical, cultural, spiritual and mental health (Department of Premier
and Cabinet, 2017). Conceptually, SEWB fundamentally aligns with the more Western,
biomedical term ‘mental health’. However, SEWB further defines the holistic concept of the
connectedness of physical, cultural and mental health experiences, capturing how
22
environmental, social, cultural and spiritual factors can impact on quality, outcomes and
experiences of an Aboriginal and Torres Strait Islander person’s life, health and wellbeing.
2.2.1 Social and emotional wellbeing transcends Western views of mental health
Ideally, Aboriginal and Torres Strait Islander peoples thrive in environments that provide a
health and wellbeing context where engagement with social, cultural, and spiritual aspects
of life are possible (Dudgeon, Bray, D'Costa & Walker, 2017). SEWB transcends Westernised
understandings of mental health that focus on internalised mental hardships and biomedical
understandings of disorders. Instead SEWB recognises the influences that Aboriginal and
Torres Strait Islander connections to Country and culture have on health and wellbeing
outcomes. While SEWB is understood to change across a lifespan, it is acknowledged that
“a positive sense of SEWB is essential for Aboriginal and Torres Strait Islander peoples to
lead successful and fulfilling lives” (Dudgeon et al., 2014, p. 58).
2.2.2 Social and emotional wellbeing involves an individual, their family and community
Achieving individual SEWB heavily relies on the collective wellbeing of Country, family,
community, culture and identity, as demonstrated in the SEWB model (Figure 1, below),
established by Gee, Dudgeon, Schultz , Hart and Kelly (2014). This model illustrates an
Aboriginal and Torres Strait Islander concept of self as being grounded by and central to, a
collectivist understanding that sees the self as embedded within family and community. It
also defines several of the domains of wellbeing that are understood to characterise and
shape individual, family and community Aboriginal and Torres Strait Islander SEWB,
including connections to spirit, spirituality and ancestors, body, mind and emotions, family
and kinship, community, culture, and Country (Dudgeon et al., 2014).
23
Figure 1: Social and Emotional Wellbeing from an Aboriginal and Torres Strait Islanders’ Perspective (Dudgeon
et al., 2014)
© Gee, Dudgeon, Schultz, Hart and Kelly, 2013 Artist: Tristan Schultz, Relative Creative.
2.2.3 Aboriginal and Torres Strait Islander cultural values as guiding principles of understanding social and emotional wellbeing
When defining SEWB, Raphael and Swan (1995) reinforce this holistic importance that
resonates with Aboriginal and Torres Strait Islander worldviews and understandings of
‘mental health’:
Health does not just mean the physical well-being of the individual but refers
to the social, emotional and cultural well-being of the whole community. This
is a whole of life view and includes the cyclical concept of life-death-life.
Health care services should strive to achieve the state where every individual
can achieve their full potential as human beings and thus bring about the
total well-being of their communities. (p. 7)
Raphael and Swan’s work, the Ways Forward national consultancy (1995) influenced the
pivotal work undertaken by the Social Health Reference Group as they worked to develop
24
the National Strategic Framework for Aboriginal and Torres Strait Islander People’s Mental
Health and Social and Emotional Well Being 2004-2009 (2004). That Strategy established
guiding principles that shape and underpin an Aboriginal and Torres Strait Islander concept
of SEWB and define several important, core Aboriginal and Torres Strait Islander cultural
values:
1. Health as holistic
2. The right to self determination
3. The need for cultural understanding
4. The impact of history in trauma and loss
5. Recognition of human rights
6. The impact of racism and stigma
7. Recognition of the centrality of kinship
8. Recognition of cultural diversity
9. Recognition of Aboriginal strengths. (2004)
While SEWB is not exclusively an Aboriginal and Torres Strait Islander concept, it is
recognised as a more culturally appropriate and meaningful way of understanding health
and wellbeing for Aboriginal and Torres Strait Islander people (Brockman & Dudgeon, 2020;
Department of the Prime Minister and Cabinet, 2017; Dudgeon, Bray & Walker, 2020;
National Aboriginal and Torres Strait Islander Health Council and National Mental Health
Working Group, 2004). Throughout this thesis the term SEWB will be used as descriptive
and inclusive of all other mental health related terminology, unless other terms are used by
specific citations.
25
Mental health and wellbeing qualitative perceptions in Western Australia of 70 Aboriginal
and Torres Strait Islander participants found that three out of every four participants,
depression was not considered to be an illness that could be clinically treated (Vicary &
Westerman, 2004). Depressive symptoms were rather explained as personal characteristics
intertwined with cultural understandings of the individual and community. These findings
allude to the need for further research about how Aboriginal and Torres Strait Islander
characteristics of varied emotional engagement with the natural, cultural, and spiritual
world are determined to effect overall social and emotional wellbeing. Vicary and
Westerman think that mainly:
The issue of truly defining Aboriginal and Torres Strait Islander mental ill
health therefore requires not just understanding the potential origin of such
problems, but also how to assess the extent to which these specific factors
are important and their implications for the individual. (2004, p. 4)
Positionality and worldviews matter when understanding SEWB for Aboriginal and Torres
Strait Islander peoples. Aboriginal and Torres Strait Islander voices and lived experiences can
contribute to developing understandings of how Westernised perceptions and practices of
SEWB were created external to Aboriginal culture and worldviews:
There remains a need for Indigenous voices to be heard in order to explore
and gain greater knowledge of their conceptualizations of mental disorders
and to consider these in relation to Western biomedical conceptualizations.
(Ypinazar, Margolis, Haswell-Elkins, & Tsey, 2007, p. 476)
26
2.3 Social and Emotional Wellbeing and mental health in Australia – what do we know?
Globally, it is argued that we are experiencing a SEWB and mental ill health epidemic (Tucci
& Moukaddam, 2017). The Australian Bureau of Statistics (ABS, 2007) found that 45% of
people aged 16 – 85 years old, had at some point lived with a mental disorder. In Australia,
anxiety disorders are ranked the fourth burden of disease and depressive disorders ranked
seventh (Australian Institute of Health and Welfare, 2020a). Expenditure on state and
territory specialised mental health services has been increasing 2.8% per year over the past
five years to 2016–17 (Australian Institute of Health and Welfare, 2019). The Second
National Child and Adolescent Mental Health and Wellbeing Survey stated that 13.9% of all
Australian children and adolescents aged between 14 and 17 had currently met criteria for a
mental health disorder (Lawrence et al., 2016). The proportion of young people
experiencing poor SEWB increases from childhood into adolescence. In 2007, 55% of the
health burden stemming from SEWB was from the 15-24 years age group, the highest
prevalence of all age groups (McGorry, 2007; McGorry, Purcell, Hickie & Jorm, 2007).
Although 17% of young people aged between 4 – 17 with a mental disorder had used some
form of SEWB service in the past 12 months, 44% had not accessed a SEWB service in the
past 12 months (Lawrence et al., 2016). Thirty percent of children and young people
reported to have, at some time, accessed SEWB services, however, 30% of all 4 – 17-year
old’s surveyed, with a mental disorder, had never used a SEWB service at all.
27
2.3.1 What do we know about Aboriginal and Torres Strait Islander Peoples’ and social and emotional wellbeing?
Aboriginal and Torres Strait Islander peoples are 2.7 times as likely to experience high or
very high levels of psychological distress compared to their non-Indigenous counterparts.
Impacts of this inequality are severe on morbidity and mortality outcomes, with Aboriginal
and Torres Strait Islander peoples being 2.1 more times likely to die before five years of
age, and experience a life expectancy gap of 10.6 (male) and 9.5 (female) years (Australian
Institute of Health and Welfare, 2018). High levels of psychological distress contributing to
poor health outcomes complexly impacts many communities’ health and wellbeing through
enabling increased vulnerabilities to risk from other health detriments. One hundred and
forty-one Aboriginal suicides occurred each year between 2011-12 to 2015-16, with data
reporting that suicide is the leading cause of death for Aboriginal and Torres Strait Islander
children aged five to 17: “Aboriginal and Torres Strait Islander child suicide was 8.3 deaths
per 100,000, compared to 2.1 per 100,000 for non-Indigenous children” (ABS, 2018) several
times more likely to die by suicide than non-Indigenous people. From all deaths classified
under injury, suicide accounts for 33% of all Aboriginal deaths (Australian Institute of Health
and Welfare (AIHW), 2020b). Remote locations had the highest rate for suicides, and whilst
male mortality occurred 2.4 more times than for non-Indigenous men, between 2011-12 to
2015-16, females had a 6% average annual increase between 2001-02 to 2015-16 (AIHW,
2020b).
Despite enhancing efforts to understand Aboriginal and Torres Strait Islander young
people’s SEWB needs, deaths from suicide for Aboriginal and Torres Strait Islander young
people aged under 24 increased from 21 to 28 per 100,000 between 2005 and 2015
(Australian Institute of Health and Welfare (AIHW), 2018) . Steady increases in rates of
28
suicide mortality were also identified across young people’s age groups, with 20 – 24-year
old’s found to have the highest suicide mortality rates at 45 per 100,000 (AIHW, 2018) .
Dudgeon and McPhee referred to a 2018 investigation into twelve suicide deaths of
Aboriginal young people in Western Australia. Highlighted findings explained that for
Aboriginal SEWB:
…shaped by the crushing effects of intergenerational trauma … It may be
time to consider whether the [government-run suicide prevention] services
themselves need to be co-designed in a completely different way that
recognise, at a foundational level, the need for a more collective and
inclusive approach towards cultural healing for Aboriginal communities.
(2019, p. 22)
Colonisation and the detriments of intergenerational trauma continue to be better
identified as deeply negative on Aboriginal and Torres Strait Islander young people’s lives.
Clustered suicides as in this case represent the vulnerability and exposure for Aboriginal and
Torres Strait Islander young people encountering poor SEWB from a young age in their
community.
2.3.2 Our Aboriginal and Torres Strait Islander population is younger and is experiencing life stressors and psychological distress early
Not only are 34% of Aboriginal and Torres Strait Islander young people under 15 years of
age, the median age is much younger (23 years) compared with the non-Indigenous
Australian median age (38 years) (AIHW, 2018) . One or two life stressors, factors affecting
Aboriginal and Torres Strait Islander young people’s positive SEWB, were experienced by
52% of young Aboriginal and Torres Strait Islander peoples in the past twelve months, with
data showing susceptibility to life stressors increasing with age. For example, 11% of 15 to
29
19-year-old young peoples experienced 3 or more stressors, growing to 16% for 20 to 24-
year-old young peoples.
Importantly, 33% of Aboriginal and Torres Strait Islander young people reported feelings of
high to very high levels of psychological distress, almost three times higher than their non-
Indigenous counterparts (13%) (AIHW, 2018).
2.3.3 The social determinants of health and social and emotional wellbeing
Boulton (2016) suggests that a social determinants-based approach to understanding SEWB
is insufficient when viewing poor health outcomes for Aboriginal and Torres Strait Islander
peoples. Often a dominant focus on a social determinants approach overpowers the
recognition of other important contributing factors to health and wellbeing of Aboriginal
and Torres Strait Islander peoples. It is imperative that the effects of structural violence,
racism, racial discrimination, denial of traditional culture, restricted identity, racism, and the
nonrecognition of Australia’s true origins be understood for the contribution they make to
SEWB in the Australian Aboriginal and Torres Strait Islander context (Paradies, 2017;
Paradies, Bastos, & Priest, 2017). Specific to this research is work that explores the impact of
racism on the SEWB of urban Aboriginal and Torres Strait Islander children and youth,
highlighting racism and discrimination as major determinants of SEWB (Priest, Baxter &
Hayes, 2012; Priest, Mackean, Davis, Briggs & Waters, 2012; Priest, Mackean, Davis, Waters
& Briggs, 2012; Priest, Thompson, Mackean, Baker & Waters, 2017; Priest, Paradies,
Gunthorpe, Cairney & Sayers, 2011). In addition to inequalities experienced within the social
determinant’s framework, Azzopardi (2018) states the need to acknowledge the oppression
that continues to negatively impact Aboriginal and Torres Strait Islander youth SEWB,
derived from transgenerational traumas of colonisation and ongoing racialized oppression.
30
2.3.4 The impact of the diversity of contemporary Australia on the social and emotional wellbeing of young people
Ansell (2016) affirms that young people’s SEWB development occurs through contextual
interactions across the social relations, social distinctions, and institutional influences that
create subjective living environments. Further, Ansell (2016) emphasises the importance of
understanding contemporary, changing environments and their impacts on young people’s
SEWB:
Overall, the daily lives and livelihoods of poor young people in both urban
and rural settings are closely shaped by environmental factors, and changing
economic, social and political conditions affect the ways in which they are
able to access, learn about and use their environments. (p.408)
More recently, the Aboriginal and Torres Strait Islander adolescent and youth health and
wellbeing report (AIHW, 2018) emphasized the importance of understanding Aboriginal and
Torres Strait Islander young people ’s differential contexts of contemporary Australia and
how these impact on SEWB. This thesis argues that the socio-cultural conditions and
environments that exist for Aboriginal and Torres Strait Islander young people are complex,
often serving as factors that perpetuate marginalisation and dismissal of Aboriginal and
Torres Strait Islander SEWB needs. If SEWB service provisions are to be improved, it is
necessary to implement practical options of care that can grasp and value the reality of
Aboriginal and Torres Strait Islander young people’s voices, experiences, and perspectives of
contemporary Australian society.
31
2.3.5 Being young and Aboriginal and Torres Strait Islander in contemporary Australia can be complex
Aboriginal and Torres Strait Islander young people living in modern Australia encounter the
effects of consolidating past atrocities, whilst also enduring modern systems and structures
that remain mostly designed under colonial influences. These structures undeniably prolong
the marginalisation of Aboriginal and Torres Strait Islander young people and mistrust in
general societal features. For Aboriginal and Torres Strait Islander young people, having a
positive identification within contemporary Australia can be complex. Positive association
with cultural identity in Aboriginal and Torres Strait Islander culture is an underlying
foundation of good social and emotional wellbeing. One qualitative study involving
Aboriginal and Torres Strait Islander young people conducted in NSW found that strength in
personal Aboriginal and Torres Strait Islander identity was deemed essential in achieving
good mental health (Williamson, Raphael, Redman, Daniels, Eades, & Mayers, 2010).
Another qualitative study focused on Aboriginal and Torres Strait Islander identity and
discourse (Fforde, Bamblett, Lovett, Gorringe, & Fogarty, 2013) iterated that without
changing the existing discourse deficit narrative that negatively continues to surround the
Aboriginal and Torres Strait Islander identity, efforts to increase health and wellbeing risk
remaining largely ineffective. Comparatively, these respective findings serve as a
representation of the contradiction that Aboriginal and Torres Strait Islander young people
face when approaching identity and belonging in modern Australia. In the former, resilience
and connection can be attached to the Aboriginal and Torres Strait Islander identity as a
source of wellbeing. For the latter, socially constructed narratives are seen to still be
negatively affecting the social distinction and alienation of the Aboriginal and Torres Strait
Islander identity in Australian society, negatively contributing to poor SEWB.
32
When discussing the pursuit of SEWB for contemporary young people, Eckersley explains
how:
The openness and complexity of life today can make finding meaning and the
qualities that contribute to it – autonomy, competence, purpose, direction,
balance, identity and belonging – extremely hard, especially for young
people, for whom these arc the destinations of the developmental journeys
they are undertaking. (2007, p. 42)
For Aboriginal and Torres Strait Islander young people, this complexity is compounded by
multiple health and social inequities.
2.4 Aboriginal and Torres Strait Islander young people- the deficit discourse
As efforts to decrease Aboriginal and Torres Strait Islander health inequality continue, we
need to consider how much deficit discourse dominates Aboriginal and Torres Strait Islander
SEWB policy, service delivery and outcomes.
Drew (2015) contradicts the negative discourse about Aboriginal and Torres Strait Islander
health and SEWB, highlighting numerous case studies of success in Aboriginal and Torres
Strait Islander young people’s SEWB outcomes. Fforde et al. (2013) critiqued the discourse
pertaining to national Aboriginal and Torres Strait Islander health campaigns, like ‘Closing
The Gap’, explaining that political and social conceptions of the Aboriginal and Torres Strait
Islander identity and health outcomes are consistently deficit, in need of constant
advancement; these lack any positive framework to highlight any strengths based
outcomes.
33
As future generations of our Aboriginal and Torres Strait Islander young people internalise
deficit discourses surrounding health, wellbeing, and identity, they increase the possibility of
negative SEWB experiences.
2.4.1 Shifting the deficit discourse and engaging with strengths
As a young Aboriginal researcher, I uphold a focus on finding ways of shifting the deficit
discourse6 that is frequently used to shape narratives about Aboriginal and Torres Strait
Islander young people’s health and wellbeing. Deficit discourse has potential to position
challenges or problems as being the responsibility of individuals, rather than considering the
wider socio-political and structural determinants of health and wellbeing. The impact of
deficit discourse on health wellbeing has been noted by Halpern (2015), while Fogarty,
Lovell, Langenberg, and Heron (2018) state that “continual reporting of negative
stereotypes and prevalence rates actually reinforces undesired behaviour” (p. vi). While this
research acknowledges that SEWB outcomes remain poorer for Aboriginal and Torres Strait
Islander young people than for their non-Indigenous counterparts (Young, Hanson, Craig,
Clapham, & Williamson, 2017) maintaining a focus on deficit discourse prohibits
opportunities to explore strengths and possibilities for making change to wellbeing
outcomes. This research sought to engage voices of Aboriginal and Torres Strait Islander
young people, to provide space for their lived experiences and ideas to be heard and valued
and to position those lived experiences within a positive, solutions-focused way of exploring
SEWB and service delivery. In essence, the research embodied what Fogarty et al. (2018)
define as a strengths based approach; research that challenges deficit thinking and
6 Deficit discourse is defined here as a narrative that represents a cohort of people in terms of deficiency, failure or lack.
34
narratives around Aboriginal and Torres Strait Islander young people and SEWB , and,
following in the footsteps of leading work in strengths based approaches sought to invest in
possibilities for systems and service change, as described directly through the insight, lived
experiences and ideas of young Aboriginal and Torres Strait Islander people (Askew et al.,
2020; Dudgeon, Bray, & Walker, 2020; Dudgeon, Bray, Walker, & Darlaston-Jones, 2020;
Milroy, Dudgeon, Cox, Georgatos, & Bray, 2017).
This chapter provided some important socio-cultural contexts of this research. It presented
a snapshot on the SEWB of young Aboriginal and Torres Strait Islander peoples and explored
varying narratives and definitions of mental health and SEWB. Importantly, it established
the central positioning of culture within one’s SEWB and highlighted some complexities
faced by contemporary young Aboriginal and Torres Strait islander peoples. The final section
provided the foundation for my determination to undertake this research through a positive
lens, through shifting an overused deficit discourse into a strengths-based narrative
centered on the lived experiences, voices and understandings of Aboriginal and Torres Strait
Islander young SEWB service users. To achieve that I needed to explore the SEWB policy
context, considering how policy changes have (or not) been influenced by lived experiences
and voices of Aboriginal and Torres Strait Islander young SEWB service users. I present that
exploration in the next chapter.
35
Chapter 3: The Social and Emotional Wellbeing Policy context
3.1 Introduction to this chapter
Equitable, appropriate, and relevant health policy is essential to achieve good health and
wellbeing outcomes. Health policy development involves government, institutional, and
health professionals coming together to develop policies that inform the production,
provision, and financing of healthcare services that impact on individual, community, and
population health (Porche, 2017). This chapter focuses on high level, national health, and
wellbeing policies. While it is important to have focused, national Aboriginal and Torres
Strait Islander health and wellbeing policies, there are limitations to acknowledge. High-end,
high-level policies have potential to adopt a one-size fits all approach that is a mismatch for
the specific needs identified at a state/territory, regional or local community level. The
strength of a national policy is to be realised as a driver for development of further policies
that address the immediate, local needs. The recent lack of successful outcomes of the
Close the Gap national policy is an example of a high level policy initiative that required
closer engagement with local needs, better alignment with more local policy and adequate
resourcing (Bond & Singh, 2020).
With Aboriginal and Torres Strait Islander SEWB having been affected detrimentally under
previous government policies (Purdie, Dudgeon, & Walker, 2010), mental health policy
analysis is beneficial when correlating the research and service provision gaps evident in
existing health inequalities of Aboriginal and Torres Strait Islander young people’s SEWB
outcomes. Contemporary Australian health policy has been described as lacking definite
planning and oversight, with multiple federal, state and territory government reforms being
36
introduced increasingly and differently based on national policies (Dugdale, 2020). As state
and territory reforms and policies are responsive to federal decision making, only national
level health policies will be reviewed in this section. Despite national health policy and
guidelines indicating priority areas and ideal outcomes for better health and SEWB, major
flaws of these documents involve lack of government accountability to report on and
achieve changes, insignificant considerations for localized needs and implementations, and
top down approaches that deny community level health issues being adequately addressed
(Hickie, Davenport, Luscombe, Groom, & McGorry, 2005).
3.2 Seminal policy work in Aboriginal and Torres Strait islander health and social and emotional wellbeing
The First National Mental Health Plan was established in 1993 (Australian Health Ministers,
1992), with the Australian government launching four further National Mental Health Plans
since then. Complementing these plans are an array of supporting policies, frameworks and
guidelines. In 1989, the National Aboriginal Health Strategy formed the first national policy
targeting the health needs of Aboriginal and Torres Strait Islander peoples (Australian
Health Ministers, 1998). Following this, Swan and Raphael’s (1995) Ways Forward report
pioneered strategic analysis of Aboriginal and Torres Strait Islander mental health and
SEWB. Nine key guiding principles are listed in the Ways Forward Report (Swan and Raphael,
1995). Aboriginal and Torres Strait Islander peoples not only have varying worldviews and
notions of SEWB to non-indigenous peoples, they have been enforced to assimilate into
health and wellbeing systems that are innately different to Aboriginal and Torres Strait
Islander ways doing, knowing, and being healthy and well. Providing key principles for
Aboriginal and Torres Strait Islander SEWB was not only beneficial for guidance on SEWB
37
systems and service reforms, it formalized ways in which differences to Australia’s bio-
medical western model of SEWB exist, demanding fundamental changes to be understood
and acted upon across governance, consultation, communication, engagement, policy and
service delivery reforms. This document is seminal to all subsequent policy frameworks and
strategic plans for Aboriginal and Torres Strait Islander mental health and SEWB.
Over the past 25 years much work has subsequently been done to address mental health
and SEWB inequities for Aboriginal and Torres Strait Islander peoples. However, despite
making innovative national level changes (Purcell, Goldstone, Moran, Albiston, Edwards,
Pennell, & McGorry, 2011), gaps still remain in policy and strategy focused to meet the
needs of Aboriginal and Torres Strait Islander young people and adults. Unfortunately,
actions listed in implemented policies have not necessarily led to outcomes being achieved,
nor necessarily been implemented at all, adding to the gaps experienced by Aboriginal and
Torres Strait Islander young people in SEWB systems. Accordingly, this chapter seeks to
synthesise mental health policy and strategic reform, with a vision to highlight the
persistent gaps in meeting the mental health and SEWB needs of Aboriginal and Torres
Strait Islander young people.
3.3 The First National Mental Health strategy 1992 – 2003
Australian public criticism, focused on mental health services, peaked in the years leading
up to 1990 (Whiteford, Buckingham, & Manderscheid, 2002) and led to the development of
a National Mental Health Policy (Plan 1) (Australian Health Ministers, 1992). Traditionally,
poor mental health was considered to reflect individual weakness and vulnerability; traits
38
that became negatively attached to those with mental health problems (Byrne, 2000).
During these formative policy years, the stigmatisation of individuals experiencing mental
health problems heavily contributed to negative overall health outcomes, with many
individuals demonized in the public domain and in the health sector (Corrigan, 2000).
Despite the lack of specific policies for Aboriginal and Torres Strait Islander peoples, a key
feature of Plan 1 (1992) was the identification of the need to shift from intervention-based
care models, those prioritising crisis and high needs mental health care, towards
prevention-based population-health care. Plan 1’s (1992) overarching goal was to establish a
framework for strategy to develop and implement evidence-based best practice, allowing
promotion and evaluation to occur in sequential mental health policy planning for several
decades (Commonwealth Department of Health and Family Services, 1997; Whiteford et al.,
2002). Essentially, Plan 1 represented a transitional process that focused on evaluating the
existing mental health system, whilst simultaneously scoping areas for reform. Important
reform priorities included enhanced promotion and prevention of mental ill health,
producing service diversity for a range of individuals impacted by mental illnesses, increased
service integration and diversity and, most notably, enhanced inclusion, input and rights of
consumers and carers (Commonwealth Department of Health and Family Services, 1997;
Whiteford et al., 2002). Notably, Aboriginal and Torres Strait Islander SEWB needs,
differences, and community identified priority areas were not mentioned in the First
National Mental Health Plan. Also lacking was any specific focus on the importance of young
people’s needs in relation to SEWB.
Misunderstandings of mental health care needs and stigmatisation at the service provider,
community, and structural levels created indifference about providing specific and
39
appropriate options for care (Corrigan, Druss, & Perlick, 2014; Corrigan, Mittal, et al., 2014).
For Aboriginal and Torres Strait Islander peoples seeking mental health support, pre-existing
cultural prejudices and social exclusion further increased the influences that such barriers
enforced, particularly so when compared to the experience of the non-Indigenous
population (Kairuz, Casanelia, Bennett-Brook, Coombes, & Yadav, 2020).
When discussing minority population groups living with mental health problems, Gary
(2005) defines the experience of double stigma as a polarizing effect that entraps minority
population groups in a discriminatory cycle of multi-faceted mental health systemic neglect
within social, clinical, academic, and political settings. As such, during these formative policy
years an Aboriginal and Torres Strait Islander person seeking support from mental health
services were likely to face what Gary (2005) named the impact of double stigma.
Unfortunately, Plan 1 (Australian Health Ministers, 1992) was unsuccessful in reforming the
experience of mental health for Aboriginal and Torres Strait Islander peoples, not least of all
that of our Aboriginal and Torres Strait Islander young peoples who received a lack of
attention in Plan 1. Although Plan 1 focused on enhancing planning and preparedness for
future implementations of system and service reforms to better meet public needs,
Aboriginal young people were not given specific consideration, continuing the inequitable
approach to improving SEWB for the future of Aboriginal and Torres Strait Islander peoples.
Despite highlighting promising reforms, Plan 1 (Australian Health Ministers, 1992) lacked
specific considerations for Aboriginal and Torres Strait Islander peoples. In the final
evaluation of the Plan (Commonwealth Department of Health and Family Services, 1997),
two of the fourteen future strategic directions (items six and seven) outlined the failure of
Plan 1’s relevance to Aboriginal and Torres Strait Islander SEWB needs, suggesting future
40
policy needs to respond to people with special needs and plan population approaches to
prevention and promotion. However, there were no specific recommendations made to
meet the needs and priorities of Aboriginal and Torres Strait Islander peoples within the
other twelve future strategic directions. Another major failure of Plan 1 (Australian Health
Ministers, 1992) was the absence of strategies to address the needs of specific age groups;
specific to this study is an absence of strategies to meet the needs of young Aboriginal and
Torres Strait Islander peoples.
3.4 The Second National Mental Health Plan 1998 – 2003
Aboriginal and Torres Strait Islander SEWB was recognised for the first time in the Second
National Mental Health Plan (Plan 2) (Australian Health Ministers, 1998). Referencing the
Ways Forward report (Swan & Raphael, 1995), recognition was made of an insufficient
focus, in Plan 1, on the needs of Aboriginal and Torres Strait Islander peoples (Australian
Health Ministers, 1992), stating “An essential principle in achieving progress for Aboriginal
and Torres Strait Islander people is to ensure that they play a central role in determining
acceptable partnerships for service reform” (Australian Health Ministers, 1998, p. 17). This
shift of focus is aligned with the growth of policy on self-determination across most
Aboriginal and Torres Strait Islander sectors at this time.
Self-determination serves as the first of sixteen policy elements outlined by Swan and
Raphael in the Ways Forward report (1995) as necessary for increased positive mental
health outcomes for Aboriginal and Torres Strait Islander Australians. Dodson’s (1994)
critique of the Federal Government’s lack of action for Aboriginal and Torres Strait Islander
self-determination in policy continued to resonate with the need for Aboriginal and Torres
41
Strait Islander peoples to be respected as an under severed and under recognised
population group that demands self- determination at the policy level, “The answer is
arrived at in reverse, by excluding those people whom the application of the right to self-
determination could entail consequences inconsistent with the interests of the state”
(Dodson, 1994, p. 6). Consequences inconsistent with state interests in this context directly
correlate with the expansion of mental health as a national priority health issue, yet
simultaneously it disguises the prolonged state of Aboriginal and Torres Strait Islander SEWB
and health deficits and inequities.
Progress resulting from Plan 1’s (Australian Health Ministers, 1992) evaluation saw Plan 2
(Australian Health Ministers, 1998) indicate needed increases in collaboration in Aboriginal
and Torres Strait Islander mental health partnerships (Australian Health Ministers, 1998),
although, progress towards Aboriginal and Torres Strait Islander community controlled
mental health care remained slow. Before national implementation of Plan 3, the Out of
Hospital, Out of Mind! Report (Groom, Hickie, & Davenport, 2003), conducted by the
Mental Health Council of Australia, sought to examine community level experiences of
mental health care across Australia. Overall, these were reported as poor, specifically when
considering accessing services, continuity of care, and inconsistences in quality of care.
Broad agreeance in participant views, under section 4.2.2.9 ‘Indigenous Communities’
(Groom et al., 2003), supported that Aboriginal and Torres Strait Islander peoples needed to
be recognized as a broader community needing a standalone priority area in National
Mental Health Policies. Adding to this need, participant feedback on the state of SEWB
policies for Aboriginal and Torres Strait Islander peoples included supporting the need to
take action and implement programs based on adequately available evidence, that
programs and services should be based on holistic models of care, focus on early
42
intervention particularly educational-school based, respect under served and under
recognised community needs, and for approaches to avoid simply focusing on illness and to
genuinely address social determinant inequalities heavily influencing poor SEWB (Groom et
al., 2003).
Rather than strategically funding Aboriginal and Torres Strait Islander community controlled
mental health services, westernized mental health processes, often with limited co-
production principles, continued to dominate. Reform, under Plan 2 (Australian Health
Ministers, 1998), needed to avoid the well-trodden path of paternalistic policy and service
development and replace it with a collaborative model that engaged with community-
controlled options (McPhail-Bell, Bond, Brough, & Fredericks, 2016). McPhail-Bell et al.
acknowledge the presence of paternalistic trends in Federal health policy, “The moral
agenda of health advancement continues to operate as a convenient disguise for exercising
control over Aboriginal and Torres Strait Islander people, informed by colonial imaginings of
Indigeneity as deficient” (2016, p. 197). For Aboriginal and Torres Strait Islander SEWB
progress to be truly inclusive, it must translate to direct ownership, production and
mediation of knowledge, all still relatively absent in Plan 2 (Singer, Bennett-Levy, &
Rotumah, 2015).
Plan 2 (Australian Health Ministers, 1998) did, however, make efforts to adopt some
suggested policy elements made in the Ways Forward report (Swan & Raphael, 1995).
Aboriginal and Torres Strait Islander voices, experiences, and perspectives, however, were
still largely ignored. This was evident in the disregard of the need for increased attention
towards the sixth policy element, ‘Aboriginal children, young people and families’.
43
Promotion and prevention, listed as the first of three priority areas, outlines the need for
the introduction of ‘selective preventive measures’; strategies that specifically relate to
mental health prevention within a particular population group (Australian Health Ministers,
1998, p. 13). In Plan 2 (Australian Health Ministers, 1998) this chosen priority population
comprised members of the Stolen Generation (Wilkie, 1997), “particularly those removed as
children from their families” (Australian Health Ministers, 1998, p. 13). Undoubtedly an
important population group, this policy choice still does not align with recommendations
made by Swan and Raphael (1995) that called for attention to the needs of Aboriginal and
Torres Strait Islander children, young people and families:
There is a virtual absence of mental health programs for Aboriginal children,
young people and families and evidence of major need in that estimates
suggest at least a third of young people have problems, and 40% of the
Aboriginal population is aged 15 years or less. (p. 10)
Raphael and Swan (1995) noted that, prior to 1994, 40% of the Aboriginal and Torres Strait
Islander population were young people aged 15 years or younger, and yet Plan 2 (Australian
Health Ministers, 1998) continued to ignore the specific mental health and SEWB needs of
Aboriginal and Torres Strait Islander young people as a policy priority.
Youth and adolescence are known to be pivotal stages of life. Individuals who experience
mental health concerns that are left unresolved during this period, risk encountering
harmful long-term health conditions, inclusive of poorer social, educational, vocational, and
SEWB outcomes (Birchwood & Singh, 2013). Research has also indicated that prevention
and intervention of young people’s mental health issues is critical for healthy development
into adulthood (Calma, Dudgeon, & Bray, 2017; Jones, 2013; Kilian & Williamson, 2018;
44
Young, Hanson, Craig, Clapham, & Williamson, 2017). Despite some transformation, Plan 2
(Australian Health Ministers, 1998) still retained a lack of policy focus that was required to
meet the specific mental health and SEWB inequalities experienced by Aboriginal and Torres
Strait Islander young people, and young people in general.
3.5 The Third National Mental Health Plan 2003 – 2008 & The National Strategic Framework for Aboriginal and Torres Strait Islander People’s Mental Health and Social and Emotional Wellbeing 2004-2009
Transitioning towards population health-based frameworks and the adoption of SEWB
concepts underpinned the Third National Mental Health Plan (Plan 3) (Australian Health
Ministers, 2003). Increasingly mental health was defined as a complex issue that is
influenced by social determinants and environmental factors. The Council of Australian
Governments (COAG) developed a National Action Plan on Mental Health (Council of
Australian Governments (COAG), Governments, 2006) that contributed the largest financial
investment ($4.6 billion) towards mental health to date. Importantly, this amount was
matched in the reform of strategic investment that saw a shift away from a health needs
approach towards a social determinants approach of systemic mental health policy reform
(COAG, 2006).
Research on the integration of social determinants of health approaches into policy found
slow policy uptake, bias towards bio-medical infrastructures, and concerns over potential
lack of achieving practical outcomes that would influence population level health and
behavior changes (Fisher, Baum, MacDougall, Newman, & McDermott, 2015). Across the
intersections of these perceived systemic and policy flaws, Aboriginal and Torres Strait
Islander young people remained inside the policy context as a hidden minority within an
existing minority group. Aboriginal and Torres Strait Islander young people continued to be
45
unrecognized as a priority population group. One intention of Plan 3 (Australian Health
Ministers, Ministers, 2003) was to produce more immediate outcomes through certain
initiatives for some specific population groups, noting the need for tailored programs for
children. However, a specific focus on Aboriginal and Torres Strait Islander young people
was still excluded (Fisher et al., 2015).
Around the same time that the Third National Mental Health Plan (Plan 3) was launched
work was being undertaken to develop the National Strategic Framework for Aboriginal and
Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2004-2009
(National Aboriginal and Torres Strait Islander Health Council and National Mental Health
Working Group, 2004). This was led by a group of Aboriginal and Torres Strait Islander SEWB
experts and continued to embed recommendations from the Ways Forward report by
recognising the need for a specific focus on the SEWB and mental health needs of Aboriginal
and Torres Strait Islander peoples. This represents a practical and strategic progression in
Federal policy and signifies the valuing of Aboriginal and Torres Strait Islander experiences
and perspectives (Laverty, McDermott, & Calma, 2017). Benefits attached to enhancing
cultural safety and practices at the Federal level of health standards are emphasised in Plan
3 (Australian Health Ministers, 2003), and are not exclusive to Aboriginal and Torres Strait
Islander peoples (Laverty et al., 2017).
Reform of Aboriginal and Torres Strait Islander mental health care, inclusive of a National
Strategic Framework for Aboriginal and Torres Strait Islander People’s Mental Health and
Social and Emotional Wellbeing 2004-2009 (Social Health Reference Group, 2004) promoted
key principles and strategic directions, being informed by Aboriginal and Torres Strait
Islander peoples. This shift subsequently refocused efforts to prioritise and address the
46
needs of Aboriginal and Torres Strait Islander young people. Children, young people,
families and communities were the first focus area of the reform (Social Health Reference
Group, 2004), with Aboriginal and Torres Strait Islander young people recognised as the
primary population group in need of receiving enhanced SEWB care, as outlined in the
SEWB framework (Social Health Reference Group, 2004).
Paramount to the recommendations of this first strategic focus are distinct action areas
oriented towards young people. The development of age appropriate assessment and
intervention strategies, increased funding targeting localised community service needs, and
the enhancement of multifaceted wellbeing services that foster positive development in
young people (Social Health Reference Group, 2004), all reinforce existing gaps for
prevention and intervention mechanisms relevant for young people’s SEWB needs.
Outcome 16 of Plan 3 (Australian Health Ministers, 2003) (Improved access to services for
Aboriginal and Torres Strait Islander people) indicated promising policy directions that
started to specifically target Aboriginal and Torres Strait Islander young people’s SEWB
needs (Australian Health Ministers,2003).
Unfortunately, the fourth priority theme of Plan 3 (Australian Health Ministers,2003)
(Fostering research, innovation and sustainability) did not translate to effective outcomes.
One systematic review of the quality of health research conducted between 1994 and 2011,
for Aboriginal and Torres Strait Islander young people aged 10 to 24 years of age (Azzopardi,
2013), found that in 2006, during the middle phase of Plan 3 (Australian Health Ministers,
2003), approximately 31.7% of the Aboriginal and Torres Strait Islander population
identified as young people, with three quarters of this population living in urban and
regional settings. However, only 17% of available research focused on urban populations.
47
Despite the increased quantity of peer reviewed research from 2003 onwards, out of the
360 peer-reviewed publications analysed, only 63 studies focused on non-communicable
diseases, and of these only 18 explored mental health disorders. Azzopardi (2013) noted
minimal research targeting Aboriginal and Torres Strait Islander young people’s mental
health, particularly in urban populations, again reinforcing the need to prioritise Aboriginal
and Torres Strait Islander young people’s voices, experiences and perspectives in SEWB
research. Importantly, Azzopardi (2013) identified the gap between Aboriginal and Torres
Strait Islander SEWB and mental health policy recommendations, inclusive of the uptake of
appropriate Aboriginal and Torres Strait Islander SEWB and mental health research. For
better Aboriginal and Torres Strait Islander SEWB outcomes to occur, policy and research
must value and include the voices, experiences, and perspectives of Aboriginal and Torres
Strait Islander peoples when conducting research and re-designing policy and services.
3.6 The Fourth National Mental Health Plan 2009 – 2014
Tailored approaches to SEWB policy and services increasingly appeared for Aboriginal and
Torres Strait Islander people and young people in the Fourth National Mental Health Plan
(Plan 4) (Commonwealth of Australia, 2009). Two of the five priority areas were focused on
developing strategic approaches to young people’s mental health and SEWB care.
Priority one (Social Inclusion and Recovery) (Commonwealth of Australia, 2009, p. 29),
demonstrates the Federal government’s required leadership to develop actions and
implement SEWB strategies that positively contribute to the Closing the Gap7 campaign.
This action appears to recycle previous promises of enhancing Aboriginal and Torres Strait
7 Closing the Gap is a formal commitment by all levels of the Australian government to achieve Aboriginal and Torres Strait Islander health equality within 25 years (Governments, 2009a).
48
Islander-specific strategies made by governments. However, one differentiating element in
Plan 4 (Commonwealth of Australia, 2009) can be identified, as with an increased focus on
Closing the Gap on health inequities, this potentially generated positive impacts on Plan 4’s
(Commonwealth of Australia, 2009) formal recognizing process of the need to improve
mental health and SEWB outcomes for Aboriginal and Torres Strait Islander peoples.
The second priority area of Plan 4, Prevention and early intervention, (Commonwealth of
Australia, 2009), sought to promote innovation and evidence-based service delivery.
Community based, accessible, cost effective and integrated services constructed on best
evidence are stated in Plan 4’s action areas. Also promoted is the need for the development
of tailored services for young people who have previously, or currently, live with the
experience of abuse and trauma (Commonwealth of Australia, 2009, p. 37). Despite not
outlining specific priorities for Aboriginal and Torres Strait Islander young people, these
national areas of action can be associated with enhanced targeted approaches that align
more closely with improvements in policy and service for Aboriginal and Torres Strait
Islander young people’s SEWB. Fisher et al. (2015) established a qualitative framework for
assessing policy uptake, with one reported outcome being an enhanced ability to
understand how perceived success measures, as framed in government policy, translated
into practical planning and implementation. Fisher et al.’s (2015) work again demonstrates
how our knowledge about what works, in policy and strategic development, increases
through listening to key qualitative data from Aboriginal and Torres Strait Islander young
people.
Plan 4 (Commonwealth of Australia, 2009) showed increased attention given to the
collection and use of mental health data within the planned reforms. However, despite a
49
subsequent increase in SEWB data being collected, data pertaining to Aboriginal and Torres
Strait Islander young people and SEWB remained limited at the national level. Whilst
acknowledging the need for evidence-based interventions and preventative service designs,
Plan 4 identified that frequently research outcomes often fail to translate to meaningful
evidence or practice. Further, research was recognised as sometimes being misdirected
away from community needs, thus failing to fulfil policy strategies for certain populations in
SEWB policy and practice reforms (Commonwealth of Australia, 2009).
Released in the same year as Plan 4 (Commonwealth of Australia, 2009), the National
Framework for Protecting Australia’s Children (COAG, 2009b) identifies Aboriginal and
Torres Strait Islander young people as a priority area for action, recommending that
“Aboriginal and Torres Strait Islander children and families are supported and safe in their
communities” (COAG, 2009b, p. 28). Under this Framework two strategies focus on the
imperative to include Aboriginal and Torres Strait Islander young people’s perspectives and
needs (COAG, 2009b). Strategy 5.1 of this Framework states the need to “Expand access to
Aboriginal and Torres Strait Islander and mainstream services for families and children”
(COAG, 2009b, p. 29), and Strategy 5.3 aims to, “Ensure that Aboriginal and Torres Strait
Islander children receive culturally appropriate protection services and care” (COAG, 2009b,
p. 30). These policy strategies rely on the promotion of a whole of community change and
commitment to addressing SEWB inequities for Aboriginal and Torres Strait Islander young
people; suggesting that a large focus be placed on the contributing factors to health and
SEWB. Together this Framework (COAG, 2009b) and Plan 4 (Commonwealth of Australia,
2009) showed potential for a strategic focus on community based programs, on trauma and
domestic violence supports, on increased SEWB literacy and education, on integration of
50
services, and specifically note the underpinning commitment to culturally appropriate
service delivery. While Plan 4 established some much needed shifts, Aboriginal and Torres
Strait Islander young people’s rightful position in informing policy and service delivery
became legitimized in the subsequent Fifth National Mental Health Plan (Commonwealth of
Australia, 2017).
3.7 The Fifth National Mental Health Plan 2017-2022
As the first National Mental Health plan to recognise Aboriginal and Torres Strait Islander
SEWB as a priority, the Fifth National Mental Health Plan (Plan 5) (Commonwealth of
Australia, 2017) served as a significant and strategic commitment from the Federal
government to improving SEWB policy and strategy for Aboriginal and Torres Strait Islander
young peoples. The establishment and implementation of the Aboriginal and Torres Strait
Islander Mental Health and Suicide Prevention Subcommittee was an invaluable addition to
Plan 5 (Commonwealth of Australia, 2017) as it provided realistic and culturally informed
policy and service strategy, aiming to avoid revisiting any previously misguided efforts. Plan
5 (Commonwealth of Australia, 2017) contains several key indicators specific to the SEWB
needs of Aboriginal and Torres Strait Islander young people.
Plan 5’s (Commonwealth of Australia, 2017) priority area 4 (Improving Aboriginal and Torres
Strait Islander mental health and suicide prevention) clearly outlines SEWB and mental
health inequities for Aboriginal and Torres Strait Islander peoples. Action areas 10
(Governments will work with Primary Health Networks (PHNs) and Local Health Networks
(LHNs) to implement integrated planning and service delivery for Aboriginal and Torres
Strait Islander peoples at the regional level), 11 (Governments will establish an Aboriginal
51
and Torres Strait Islander Mental Health and Suicide Prevention Subcommittee of Mental
Health Drug and Alcohol Principal Committee (MHDAPC) ), and 12 (Governments will
improve Aboriginal and Torres Strait Islander access to, and experience with, mental health
and wellbeing services in collaboration with ACCHSs and other service providers)
(Commonwealth of Australia, 2017, pp. 33-35) presented opportunities not only to co-
produce SEWB and suicide prevention services with communities, but also highlight
opportunities to work with specific cohorts. Specific to this study is the potential for Plan 5
(Commonwealth of Australia, 2017) to engage with Aboriginal and Torres Strait Islander
young people through the inclusion of Aboriginal and Torres Strait Islander young people in
“a strong presence of Aboriginal and Torres Strait Islander leadership on local mental health
service and related area service governance structures” (Commonwealth of Australia, 2017,
p. 33). Additionally, Plan 5’s priority area 4 also realises the scope for including young
people in processes of “developing and distributing a compendium of resources”
(Commonwealth of Australia, 2017, p. 34) that appropriately target the SEWB needs of
Aboriginal and Torres Strait Islander young people. Plan 5 showed potential to utilise
Aboriginal and Torres Strait Islander young people’s voices, experiences and perspectives as
data to ensure “that future investments are properly evaluated to inform what works”
(Commonwealth of Australia, 2017, p. 34). Plan 5’s recognition that Aboriginal and Torres
Strait Islander mental health inequalities frequently relate to intersecting health and
wellbeing barriers was progressive and called for further exploration (Commonwealth of
Australia, 2017). This laid the foundations for inclusion of Aboriginal and Torres Strait
Islander young people, to help policy and decision makers better understand the barriers
and enablers associated with positive or negative SEWB experiences for Aboriginal and
Torres Strait Islander young people.
52
In Plan 5, ACCHSs were positioned as crucial to supporting enhanced cultural competency
and Aboriginal and Torres Strait Islander-led service and system reform (Commonwealth of
Australia, 2017, p. 31). This positioning held considerable importance across Plan 5, stating
clearly that the majority of ACCHSs serve as the first point of contact for Aboriginal and
Torres Strait Islander SEWB services in many Aboriginal and Torres Strait Islander
communities. Key factors to the proposed success of strategic focus on ACCHSs in Plan 5
included the ability for ACCHSs to provide culturally appropriate understandings of SEWB
challenges, provide consistent services that meet the needs of Aboriginal and Torres Strait
Islander clients, engage with integrated and holistic approaches to care, and ensure the
presence of Aboriginal and Torres Strait Islander staff who seek to reduce the commonly
experienced fear of judgment, stigma and discrimination often experienced by SEWB
Aboriginal and Torres Strait Islander clients. Reinforcing the importance of community
driven approaches to successful service reform was further explained under priority area 8,
“Ensuring that the enablers of effective system performance and system improvement are
in place” (Commonwealth of Australia, 2017, p. 46). When reforming Aboriginal and Torres
Strait Islander young people’s SEWB services, in line with priority area 8, action needed to
consider how to reduce the disparities between ineffective research outputs, poor
knowledge translation to services and, above all, needed to establish ways to ensure direct
involvement of Aboriginal and Torres Strait Islander young people as consumers when
policy, strategy and services were being established. (Commonwealth of Australia, 2017, p.
46).
53
3.8 The National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2017 – 2023 As previously outlined in the introduction to this chapter, the National Strategic Framework
for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional
Wellbeing 2017-2023 (the SEWB Framework) acknowledges the history of SEWB and mental
health policy development specific to Aboriginal and Torres Strait Islander peoples and aims
to respond to “the high incidence of social and emotional wellbeing problems and mental ill-
health, by providing a Framework for action” (Department of the Prime Minister and
Cabinet, 2017, p. 2). The SEWB Framework clearly and actively aligns itself with other
relevant policy and plans, including but not limited to, the National Aboriginal and Torres
Strait Islander Health Plan 2012-2023 (Department of Health and Ageing, 2013a) and its
Implementation Plan (Department of Health, 2014), the National Aboriginal and Torres
Strait Islander Peoples’ Drug Strategy 2014-2019 (Australian Government, 2016), the
revised COAG Closing the Gap targets (Commonwealth of Australia, 2018; Department of
Prime Minister and Cabinet, 2017), and the National Aboriginal and Torres Strait Islander
Suicide Prevention Strategy (Department of Health and Ageing, 2013b). Of particular
importance is the establishment of the Aboriginal and Torres Strait Islander Mental Health
and Suicide Prevention Advisory Group, appointed to renew the existing policy and develop
the SEWB Framework. The SEWB Framework notes the successes, and failures, of previous
policies and frameworks and specifies the positive influences it draws upon from previous
policy, strategy or frameworks, including the Ways Forward report (Swan & Raphael, 1995)
and the 2004 SEWB Framework (National Aboriginal and Torres Strait Islander Health
Council and National Mental Health Working Group, 2004) that both emphasise an
54
Aboriginal and Torres Strait Islander holistic understanding of health and wellbeing. Of specific
relevance to this study is that one of the key areas for focus in the SEWB Framework is a “focus
on children and young people” (Department of the Prime Minister and Cabinet, 2017, p. 12),
providing scope for specific policy, strategy and service development across the entire SEWB
Framework. In all six action areas, within many key strategies and example actions, young
people are explicitly named; this marks a great shift from previous policy and strategies that
demonstrated less of a consistent focus on the needs of Aboriginal and Torres Strait Islander
young peoples. The SEWB Framework provides example actions to ensure that Aboriginal and
Torres Strait Islander lived experiences of SEWB are included in policy, strategy, and service
development. For example, one action under Outcome 1.3 (Effective partnerships between
Primary Health Networks and Aboriginal Community Controlled Health Services) it states the
need to “Engage Aboriginal and Torres Strait Islander communities in the co- design of all
aspects of regional planning and service delivery” (Department of the Prime Minister and
Cabinet, 2017, p. 19). While there is no specific action for the inclusion of Aboriginal and
Torres Strait Islander young people in the collaborative and co-design phases, there remains
hope that the SEWB Framework’s strong focus for meeting the needs of young people will
encourage participation of Aboriginal young people.
3.9 Chapter summary
Mental health and SEWB have been recognised as major challenges for the medical and
wellbeing community of the 21st century (Brundtland, 2000; Purcell et al., 2011). This
applies to Aboriginal and Torres Strait Islander young people who have mental health and
wellbeing conditions “in the top four conditions contributing to their overall burden of
disease” (AIHW, 2018, p. 127), with Aboriginal and Torres Strait Islander young people
55
experiencing higher rates (almost double) of long term mental health conditions than non-
Indigenous young people, more than double the hospitalizations for intentional self-harm
than their non-Indigenous counterparts and four times the mortality due to intentional self-
harm (AIHW, 2018, p. 156).
Part of this challenge involves the need to properly understand the most suitable
preventions and interventions for Aboriginal and Torres Strait Islander young people,
moving away from the more paternalistic way of designing policy and services that does not
adequately engage with communities and individual consumers. As such, a key development
in understanding successful SEWB care has been seen through the movement towards the
creation of services that reflect the diversity of cultural, social, community, and individual
needs (McGorry, Bates, & Birchwood, 2013). However, for Aboriginal and Torres Strait
Islander young people, such efforts have only recently been made, with few positive
outcomes to date (for example, Farnbach, Eades, Fernando, Gwynn, Glozier, & Hackett,
2017; Farnbach, Eades, Gwynn, Glozier, & Hackett, 2018; Murrup-Stewart, Searle, Jobson, &
Adams, 2018; Skerrett, Gibson, Darwin, Lewis, Rallah, & De Leo, 2018).
While policy frameworks and strategies have developed a more youth-focused position over
the last few decades, there remains inadequate specificity of actions to ensure inclusion of
Aboriginal and Torres Strait Islander young peoples’ voices during the collaboration and co-
creation phases of SEWB policy and service development. Ensuring those voices are
included and heard needs to be a major focus for any subsequent SEWB and mental health
policy or strategy if future improvements are to occur. The following methodology and
methods chapter remains true to this as it describes how my research maintained Aboriginal
and Torres Strait Islander voices and lived experiences as core in the research.
56
Chapter 4: Methodology and Methods
4.1 Introduction
This chapter provides the research context for my study and describes my methodology that
maintains Aboriginal and Torres Strait Islander peoples, voices and lived experiences as
central. It also summarises the study ethics, recruitment, data collection and analysis.
4.2 Research ‘with’ not ‘on’ Aboriginal and Torres Strait Islander peoples and communities
A long history of ‘doing’ research ‘on’, not ‘with’, Aboriginal and Torres Strait Islander
peoples and communities, resulted in negative experiences of research that were often
deficit focused and had little benefit to Aboriginal and Torres Strait Islander peoples or
communities (Humphery, 2001; Thomas, Bainbridge, & Tsey, 2014; Walter, 2005).
Fortunately, major reforms in Aboriginal and Torres Strait Islander research have resulted in
the establishment of national ethical guidelines for research involving Aboriginal and Torres
Strait Islander peoples and communities. These guidelines ensure greater control and
ownership throughout the entire research process (National Health and Medical Research
Council, 2018a, 2018b).
In 2004 the Coalition for Research to Improve Aboriginal Health (CRIAH) was formed from a
collaboration between the Sax Institute (an organisation that connects researchers, policy
makers and service delivery agencies to ensure evidence-based health policy) and the
Aboriginal Health and Medical Research Council of NSW (AHMRC), the peak body for
Aboriginal health in New South Wales. CRIAH’s mandates include building Aboriginal and
Torres Strait Islander research capacity, partnerships and policy, with a particular focus on
57
building genuine research partnerships between Aboriginal and Torres Strait Islander
communities and researchers. CRIAH identified the need for research to further explore the
health and wellbeing needs and priorities of urban Aboriginal people and, after extensive
consultation with Aboriginal communities, the Study of Environment on Aboriginal
Resilience and Child Health (SEARCH) was established.
4.3 The SEARCH Study
The Study of Environment on Aboriginal Resilience and Child Health (SEARCH) has been
operational for the past twelve years. SEARCH established authentic and collaborative
partnerships between Aboriginal and non-Indigenous researchers, Aboriginal health and
wellbeing leaders and four Aboriginal Community Controlled Health Services (ACCHS) , the
latter located in urban and regional areas in New South Wales (SEARCH Investigators, 2010;
Wright et al., 2016; Young et al., 2016). Importantly all SEARCH research is co designed and
co conducted with Aboriginal and Torres Strait Islander health professionals and
communities, who also have ownership of the data (Sherriff et al., 2019). SEARCH aims to
research factors relating or contributing to the health and wellbeing of Aboriginal children
and their caregivers. Phase 1 SEARCH data involved 1669 children and their caregivers, all
who attended an ACCHS partnered with SEARCH and had parental consent provided from
parents aged >16 (SEARCH Investigators, 2010). Data was collected by SEARCH across
several domains, including family and community factors, socioeconomic factors, health and
wellbeing measures and clinical measures. Although SEARCH priorities have explored
important cultural, social, environmental, and personal health factors gaining data through
varied methods, the focus of this methods section will relate solely to the SEWB priority
research process undertaken to fulfill this thesis.
58
The SEARCH survey was based on the Western Australian Aboriginal Child Health Survey
(Zubrick et al., 2005) and the NSW Population Health Survey (Steel, 2008). The longitudinal
data collection within the SEARCH cohort included clinical measures and approved data
linkage. The protocol for SEARCH is described in more details in the published protocol
(SEARCH Investigators, 2010).
SEARCH Phase 2 included follow up surveys and several new sub studies which focused on
particular priority areas for partner ACCHSs. The data presented in this study emerges from
a sub study focused on examining how well local mental health service systems were
working for Aboriginal8 children and young people aged 16 to 25 years of age and was
collected between 2017 and 2019 being used for this specific study. The methods for this
sub study will be described in section 4.4. SEARCH remains the largest longitudinal study of
urban Aboriginal children in Australia.
4.3.1 The contributions of this thesis to the broader SEARCH study
SEARCH works to assist ACCHSs to investigate community health priorities, utilizing research
data to lobby for and inform evidence-based reforms. SEARCH has two main components as
a study; a longitudinal cohort of children and families who participated in two rounds of
data collection through surveys and clinical measures allowing consented data collection
and linkage, and priority areas specifically focused on areas including ear health, nutrition
and obesity, cardiovascular, kidney, and environmental health, and this study contributes to
the priority area of SEWB. Contribution to these ongoing partnerships and outcomes was
8 Young people participating in this study refer to themselves as Aboriginal. Out of respect, from this point in the thesis, I will use that term when referring to this study and the study participants, young Aboriginal people.
59
achieved in multiple ways in the process of composing this thesis. Being a young Koori
academic enhanced the likelihood of Aboriginal young people feeling comfortable and
respected in an academic and health research environment. This successfully allowed
culturally safe spaces for Aboriginal young people to share unique SEWB service
experiences. Working alongside Aboriginal and non-Indigenous SEARCH researchers who
have consistently built upon these relationships over many years furthered this. SEARCH
remains true to community engagement protocols, also involving parents and caregivers,
health workers, and community stakeholders who shared SEWB service and system
experiences from their respective positions. Viewing the thesis as a platform where data
would be reported on and utilized for SEWB service reforms was important for SEARCH and
ACCHSs interests primarily, yet simultaneously, the author viewed the composition of this
thesis as an opportunity to critically evaluate the ways in which Aboriginal young people
need to be better included in qualitative health research if improvements in SEWB
outcomes are to occur. As SEARCH focuses on investigating data pertaining to various
cultural, social and environmental considerations across multiple health issues, the value of
contributing deeper analysis of the values in engaging Aboriginal young people with
qualitative health research will hopefully support future successful inclusions of Aboriginal
young people as participants in SEARCH and other studies across all health issues to come.
While my research forms one part of a larger body of work undertaken as part of the
SEARCH study, specific to my research, presented in this thesis, are the roles I undertook,
including contributing to the design of the interview schedule, ensuring ongoing
engagement and liaison with the ACCHS (see Appendix 2 for examples of this process),
working with the ACCHS staff to schedule the interviews with Aboriginal young people and
60
leading the interviews with Aboriginal young people. Following data collection, I also led the
coding and analysis of the Aboriginal young people data and regularly fed back research
progress to the ACCHS and connected stakeholders. Prior to submission of this thesis I
presented an overview and key findings to the chief executives (CEs) of the participating
ACCHS. As an interactive session this provided scope for questions, clarification and for the
CEs final endorsement of the research and the written version of the thesis. A letter of
approval for submission has been provided by each CE (Appendix 3). I undertook this
research firstly as a young Koori person and secondly, as a young Koori researcher. This
intersectionality positioned me in a unique space and allowed me to create and ensure a
safe space for this research to be done with young Aboriginal peoples.
4.4 Research design
This study is part of a larger body of work that forms the SEARCH research program and its
design follows requirements established in the original protocol (SEARCH Investigators,
2010). The Consolidated Criteria for Reporting Qualitative Studies (COREQ) was also used to
inform the design and reporting of this research (Tong, Sainsbury, & Craig, 2007).
4.4.1 Ethics approvals
Ethics approval for this research was obtained under the application “Community-driven
approaches to mental health service system improvements for Aboriginal children and
young people”, granted by the Human Research Ethics Committee, South Western Sydney
Local Health District, NSW Health (local project number HE18/173 and HREC Reference:
HREC/18/LPOOL/275). That approval also provided additional approvals from the Aboriginal
Health and Medical Research Council and participating ACCHSs.
61
4.4.2 Recruitment and participants
Face to face, in-depth interviews were held with 10 Aboriginal young people (aged 16 to 24)
at two ACCHSs in NSW, who participate in the SEARCH study (SEARCH Investigators, 2010).
ACCHSs are Aboriginal governed and community driven medical services, vital in the
provision of successful and culturally safe health care for Aboriginal and Torres Strait
Islander communities. To uphold the anonymity of the young Aboriginal participants, no
identification of the participating ACCHSs will be included, other than the location of one
ACCHSs was in an urban setting and one was in a regional location. Purposive sampling was
used to include Aboriginal young people, who were users of the collaborating ACCHSs. The
researchers initially met with ACCHS staff members whose roles focused on SEWB, both
known to each other through the existing SEARCH collaborations, with one ACCHS working
with the SEARCH Aboriginal Research Officer across the region to help identify potential
local participants. The ACCHS staff members identified potential participants who they felt
could offer useful reflections on their lived experiences of using SEWB services.
Eligibility criteria were developed through the joint work of SEARCH researchers and ACCHS
Aboriginal Health workers. To meet eligibility, participants had to identify as Aboriginal and
Torres Strait Islander, be aged between 16 – 25 years of age, and have used a mental health
or SEWB service within the local health district in previous twelve months. Participants were
recruited initially through the ACCHS staff members by telephone or asked in person, where
it was declared that participants would have to be willing to provide written informed
consent.
SEARCH researchers, including me, would then call participants to introduce the study in
greater depth, ask formally if they would happy to be interviewed with audio recording, and
62
examine the results of Kessler 10 Psychological Distress Scale (K10) screenings (Kessler et al.,
2002). Participants scoring ≤21 on the study followed the Australian Bureau of Statistics’
scoring processes, naming ≤21 as low/moderate psychological distress and ≥22 as indicative
of high psychological distress (ABS, 2008). The K10 is a well-known screening tool used to
measure severity and frequency of anxiety and depressive symptoms that has been
supported as promising for screening with Aboriginal and Torres Strait Islander peoples
(McNamara, Banks, Gubhaju, Williamson, Joshy, Raphael, & Eades, 2014). Typically scores
range between 10 and 50, with scores in the higher ranges indicating more distress.
Participants were not eligible for the in-depth interviews if a K10 scoring resulted in very
high levels >30 of psychological stress or were considered by ACCHS staff to be too unwell to
be a participant.
4.4.3 Participant Welfare
Respecting that Aboriginal young people were participants bravely sharing SEWB service
experiences, participant welfare measures were established to mitigate exploring
potentially negative and harmful personal SEWB experiences during interviews. Prior to
commencing an interview, SEARCH researchers and each participant would have a yarn to
familiarize and recognise this was a culturally safe space with complete anonymity.
Participants were informed that at any time should they wish to stop or pause the interview
they could. ACCHS SEWB staff always offered to be present for each interview, if not
required, they would assist with introductions and finishing up the interview process.
63
4.4.4 Data collection
A grounded approach informed the data collection framework of this study (Tong et al.,
2007). However, Yarning was used as a method for data collection. Yarning is well known as
an Indigenous research method that engages participants in research through culturally
familiar ways of collecting data (Bessarab & Ng'andu, 2010; Geia, Hayes, & Usher, 2013;
Priest et al., 2017; Walker, Fredericks, Mills, & Anderson, 2014). The use of Yarning as an
Indigenous research method was culturally appropriate for me, as an Aboriginal researcher
and for the Aboriginal participants of my study. It allowed me to follow the approved
protocol whilst also engaging with the participants in an authentic manner that
demonstrated respect, reciprocity and cultural propriety; importantly it allowed me to enact
my own commitment to doing research “with” (not on) Aboriginal participants.
An interview guide was developed based on input from current SEWB literature and from
other research team members (Appendix 1). Following SEARCH protocols (SEARCH
Investigators, 2010), interviews were to be carried out by both an Aboriginal researcher
(me) and either another Aboriginal research colleague, Janice Nixon or Mandy Cutmore, or a
non-Indigenous research colleague, Christian Young, ensuring a gender presentation and a
small team of two researchers. Members of the research team had undertaken cultural
training and research method training in the use of yarning. The yarning-interviews were
held at ACCHS sites at times convenient for the participants. Participation was voluntary and
all participants provided written, informed consent. Recruitment stopped once data
saturation was reached at both sites. A large amount of rich data was obtained from the ten
in-depth interviews. Interviews were audio recorded, with permission, and transcribed.
64
4.4.5 Analysis
Thematic analysis was used to analyse the data. I undertook individual reading and coding of
the transcripts, identifying conceptual connections between themes, largely following Braun
and Clarke’s six phases of thematic analysis (Braun & Clarke, 2006). I developed a thematic
schema that I then took to a small group analysis session, involving other SEARCH qualitative
researchers. As this study is part of the larger SEARCH body of work, the small group of
SEARCH qualitative researchers also independently read and coded the transcripts to
inductively identify emergent themes. We met several times to discuss choices of coding
and coding structures. I used the group analysis sessions to triangulate my own coding
structures that I used for the final analysis.
65
Chapter 5: Results
5.1 Introduction
Ten young Aboriginal people participated in the yarning in-depth interviews. Seven
participants were female and three were male, five used SEWB services in an urban ACCHS
context and five in a regional ACCHS context. Participants were aged between 16 – 24 and
the average age of participants was 21.
The average duration of the yarning in-depth interviews was 22 minutes (range: 16 to 30
minutes). Each young person (YP) participant was given a pseudonym code, for example YP
2102. These pseudonyms are used throughout this results chapter.
I identified four themes: knowing what SEWB services exist and early intervention, accessing
SEWB services, cultural safety, service Integration; each theme has several sub-themes,
described below.
5.2 : Theme 1- Knowing what SEWB services exist and early intervention
Participants promoted the need for increasing the availability of early intervention programs
and services. Although Aboriginal young people reported that many SEWB services in their
area were thought to exist, lack of knowledge existed as to where these services actually
are, with particular access issues involving gaps in early interventions and absences of
multifaceted programs and services holistically supporting positive SEWB. While few early
intervention programs currently existed in the areas that participants lived, there were key
areas that participants wanted more attention given to. Overall, multifaceted services and
programs that move beyond being purely SEWB care-focused were identified.
66
5.2.1 ACCHSs primary providers of SEWB care
Aboriginal young people were more likely to use an ACCHS as the main point of reference
for information on access and use of the mainstream system. Importantly, all participants
were recruited through ACCHSs, evidence of the leadership in providing SEWB support
and care:
I think that most of the people I know that access mental health services, they've gone through (the ACCHS). I don't really know much more of any other ones around. (YP5104)
5.2.2 Challenges in knowing how to get SEWB support and services
Although many SEWB services exist, the mainstream system was found to be difficult to
navigate for participants, all Aboriginal young people. Participants noted that accessing
appropriate and ideal services could not be achieved without knowing what SEWB services
exist. Key areas were identified by participants that act as barriers when beginning the
process of accessing pathways to care. Participants identified that seeking SEWB care can be
a scary process that may involve feeling shame and being nervous about asking for help.
Combining the hardships of experiencing negative SEWB with uncertainties of how to find
SEWB help while feeling these emotions was a major barrier:
If you don’t know where to start, you think like, you know, you're just like, you’re just not sure, you’re not sure about it. It makes you just not want to get help kind of thing. (YP2102)
Yeah, and - people don't know about them and also, I feel like they're scared to ask for it. They probably need someone to ask them before they ask for it. (YP5104)
67
Other participants focused on the need to have more of a presence in the early intervention
space, noting that without consistent information and promotion of why earlier intervention
is good, young Aboriginal people will continue to fall through the cracks of SEWB systems
and service delivery:
Even social media because you can't have physical posters and stuff down here. It won't last long. Even if (the ACCHS) puts up a post, how they say it ain't weak to speak and things like that, I've noticed lately I've seen a few people on my Facebook who do go to (the ACCHS) have been sharing their story and stuff just because of all that it ain't weak to speak stuff going around. So just, yeah, like a Facebook post saying it's normal to talk about things like that. (YP5103)
Only two participants voiced that it was not too difficult to locate options of care. However,
the sense of having adequate autonomy to do so was perceived as challenging. Lack of
clarity surrounding why accessing SEWB care can be beneficial, and how to approach
discussing doing so were highlighted as potential solutions:
Yeah. I feel like the hardest part, it's available, but the hardest part is building up to go to it. It's easy and accessible. You just rock up and it's fine but that's the hardest part, I guess. That's why I feel like the advertisement and the talking about it would be the starting point for that. (YP5103)
I just feel like if they made it more, not more accessible because it is, it's easy to walk in, but no-one knows what to do sort of thing in this area, I guess. (YP5103)
Clear communication between a clinician and client, and provision of service availability and
SEWB information was noted as helpful, supporting other participants’ views about the
importance of having more knowledge of how to access the SEWB system:
Yeah, like he printed out information sheets and things to enter out for your own personal review sort of thing to reflect on what you're feeling and things
68
like that. I think that was a good idea just to reflect on why and what's making me feel like that. (YP5103)
5.2.3 A need for more information about options for SEWB support
Commonly, participants expressed the need for more accessible information on available
options of SEWB care. Participants had clear ideas about how such information could be
promoted to young Aboriginal people. Advertising was, on numerous occasions, stated by
different participants as important if Aboriginal young people were to be better equipped to
access SEWB care:
I don't think there's enough advertisement. But, and also, they're embarrassed to ask for help. (YP5102)
Well I just feel like at the moment there's not a lot of, not advertisement, but representation. I didn't know about any of it until I went and had to go in myself sort of thing. (YP5103)
Advertising would help. Kids are all into technology these days so advertisement on phones or in their schools or, even if parents talk about it at home. I know growing up that no one ever talked about that in their household. (YP5102)
5.2.4 A need for information to help understand what SEWB support is like
Aboriginal young people also spoke of a need for more information about the SEWB care
context and experience. One participant found that not knowing the processes of what
happens in SEWB care was a barrier:
Just not knowing what you’re in for, I guess. Like just not knowing what’s going to happen and what could happen. It’s more about like not wanting to talk. I’m - a lot of people don’t realise that you got to talk about it, because you’re not going to get nowhere if you don’t. (YP2102)
Ideally, early intervention supports would exist before SEWB issues were experienced at a
69
threatening level. Provision of accessible information on SEWB care was
suggested as important for help seeking to increase. Enhancing this information involves
helping Aboriginal young people know what help is available, what the SEWB help-seeking
process involves, and how to navigate systems to find helpful services and programs:
I just think getting the support in there before it gets to that stage and letting them know that there is someone there. I guess they probably feel like they don't have anybody out there. I feel like it'd be good if it was more clear to people that there is that help there. (YP5104)
5.2.5 Schools and education-based programs as key opportunities for early intervention
Early intervention programs in schools were frequently discussed as being needed yet
currently being largely absent. Interestingly, participants clearly had well-formed ideas for
what might work well in the school SEWB health education space. Some suggestions
included having more people with skills and knowledge to identify at risk students, more
opportunities to present SEWB health education presentations at schools and other
educational settings, and having extra support people available as an early intervention
initiative:
I probably would if you got people to go to schools and just sit down and have a chat with the kids and then just be like, look, if anyone's feeling down or something, you know, you can come and have a chat after the… (YP5102)
I know (ACCHS Aboriginal staff member) and he helps out with the young fellas and that. I know it like happens and that but probably not as much as it should you know. They should be going into the schools and talking to the schools about that. You know like talking to the schools about the kids that need extra help because you can tell from the kid who goes to school and mucks up at school that he’s not having a good feeling outside of school you know. His routine isn’t good outside of school…(YP2102)
70
If you're looking at younger kids at school, like going to the Aboriginal liaison officer at school with your thoughts or anything like that could help and then I guess they can refer to seeing the doctor on going on from there, going to Headspace; things like that. (YP5102)
But, they're not known, you know, why aren't they out in the schools grabbing them and doing talks and presentations or trying to make a day out of it or do a holiday - something in the holidays for the kids or something like that. (YP5102)
5.2.6 Outreach services considered to be effective
Outreach services offer flexibility in the provision of SEWB care by engaging and interacting
with clients through varied methods of SEWB care that are provided outside of traditional
clinical and service settings. Outreach programs were seen not only as being more efficient
regarding accessing SEWB care when living with difficult SEWB circumstances, but they were
also viewed as beneficial in building relationships between SEWB health workers and clients.
Participants felt that SEWB outreach work contributed to developing a better understanding
of the contexts, lives and needs of young Aboriginal people:
So, people you know, say if they’re like mental health people and that, they see a kid, they just see him - there’s a better way to get to know them you know what I mean. Like go up to the [unclear] see what they're dealing with you know. Then they'd be able to - it’ll help you help them, you know what I mean? (YP2102)
Another participant highlighted that SEWB outreach services should not just be reserved for
young Aboriginal people. SEWB outreach is a whole of community need, indicating that
SEWB outreach service options that cater to all community members are needed:
Well more of an outreach program really. Not just for minors, not just for teenagers. Need it for all age barriers [sic]. There’s all Elders out there looking for jobs and whatnot and needing help and everything like that but still, no one’s getting support. (YP2104)
71
5.3 : Theme 2- Accessing SEWB services
5.3.1 Aboriginal Community Controlled Health Services (ACCHSs)
In this study, ACCHSs were reported by participants to be the primary SEWB service
providers for Aboriginal young people. In general, participants reported positive SEWB
service experiences when accessing an ACCHS, although a small number of negative
experiences existed. While many of the services offered by ACCHS in relation to SEWB are
also offered at mainstream SEWB services (e.g. appointments with psychologists), ACCHSs
SEWB services were identified by all participants as more genuinely supportive and relevant
to what Aboriginal young people required in their SEWB-needs context.
5.3.2 Approachability and flexibility of ACCHSs
Aboriginal young people requiring SEWB care felt more comfortable approaching an ACCHS
than a mainstream service for support. One participant explained that by having access to
an Aboriginal governed organisation, as an Aboriginal young male, this meant he didn’t have
to question whether support would be provided:
Yeah, like here you know that there’s always help here for a black fella, there’s always help here but it’s still hard to even go and ask for it, you know what I mean… (YP2102)
Providing immediate and sudden access to SEWB services was important for participants.
Having a SEWB service that was responsive to an immediate need was considered essential
and positive:
Yeah, you can just call up and the girls straight away direct you to where you need to go. Yeah, you can book an appointment. For a crisis, like I said before, you can just drop in or they can come out to you. They're quite flexible, yeah. (YP2101)
72
Lived SEWB experiences of Aboriginal health workers at ACCHSs allowed Aboriginal young
people to feel less judged when accessing and utilising SEWB care compared to mainstream
SEWB services:
Yeah, they just felt like – to me it felt like they were literally just judging everything that I was telling them. So, it just didn’t make me feel comfortable at all, whereas when I went to (the ACCHS) it wasn’t like that, they weren’t judging me. They knew – they kind of knew the experiences that I’ve come from. So, they were able to help me pretty well. (YP1505)
5.3.3 Outreach services from the ACCHSs
Physically, having capacity to access SEWB services was a common challenge for
participants. SEWB service options from the ACCHSs were regarded as beneficial for
multiple reasons, including outreach helping to overcome anxiety associated with having to
go into a service and the flexibility outreach SEWB services offer:
I think out here is really good, how - especially like I was saying before, probably multiple times that you guys can actually outreach and come out to people. Whereas if they're having anxiety and they really can't bring themselves to come in here, you guys are willing to come out to them, which is really good. (YP2101)
5.3.4 Shortfalls in using ACCHS SEWB services
Participants who had utilised SEWB care through the ACCHSs did think that there were
improvements that could enhance overall access. Limited service delivery hours were
identified as a barrier to accessing SEWB services:
Well, the service here is really, really good. The only thing is it's not open late. It's only during office hours. They told me if there's ever a problem to drop straight in, but the thing is the problems have always happened when you aren't open. (YP2101)
73
Long waiting times experienced when wanting to access ACCHS SEWB services were
considered a problem:
The only probably thing is waiting times. Just if you've got an appointment or anything like that, it's probably the only thing. But everywhere is like that. I think it's just always understaffed and busy, yeah, due to high demand. (YP2101)
No, I didn’t look at anywhere. I think I’m just a person that just stay home. When I wanted to come to (the ACCHS), I come to (the ACCHS). The only thing that’s really hard with (the ACCHS) is just the slowness. (YP2105)
Not being able to access transport to the ACCHS SEWB services was a challenge:
Transfer. Transport. Yeah and you can’t get the transport because the only transport is for Elders. (YP2105)
Lack of continuity of SEWB service and follow up was also considered to be a deficit in the
ACCHS SEWB model by one participant:
I guess - because (the ACCHS) just kind of - like, you go to (the ACCHS) with your problems and they refer out… ... is the kind of the feeling you get. But if - and they don't really follow up either. They kind of just, here's your referral…(YP5102)
5.3.5 Mainstream system SEWB services
Participants reported that mainstream SEWB services were providing minimal positive
assistance for Aboriginal young people living with poor SEWB. Importantly, participants
perceived the mainstream system as crisis driven. A recurring comment was the feeling that
a young Aboriginal person needed to be at the extreme end of the SEWB care spectrum for
SEWB care to be offered. Participants were largely unaware of alternative options of SEWB
care in the mainstream system, other than crisis interventions. However, participants did
74
have firm ideas of what mainstream SEWB reforms could offer to be more suited to
Aboriginal young people.
5.3.6 An absence of alternative options for SEWB care
As mainstream SEWB services were deemed insufficiently accessible by participants, ideas
for reforms were voiced. Suggestions that participants identified were not complicated;
simply, they suggested an enhanced focus on supporting young Aboriginal people who are
attempting to navigate the mainstream SEWB system:
Just definitely a more supports-based service, and if you're going to be accessing [SEWB] through mainstream, the mainstream needs a whole big overhaul especially. Because you can't access it. It's all for show. (YP2101)
It definitely does need extra support, especially if it's out of the grounds of here. I think if it's more in a mainstream environment where you're getting assistance from, I think there needs to be more support especially for Aboriginal people, but also the normal community as well. Because it seems like nobody can really access it. It's all just for show, practically. Yeah. (YP 2101)
Participants were aware of suitable, alternative options for SEWB care in mainstream
systems. Most participants expressed that holistic based, early intervention services were
somewhere to be found in mainstream SEWB services, but they were not being promoted
sufficiently. However, participants were aware of only a limited number of holistic SEWB
mainstream services and questioned why, within a large system capable of implementing
similar services, there are so few available:
Well, I wouldn't have a clue. But I know that when he went to school that's all
he did, he hung around that group of people, like the Clontarf, and it must
have helped him some way, talked about his problems or something. I don't
know. But it changed him. (YP5102)
75
One of the other programs is very in touch with their clients. I can't even
think of what the program was. They go do house visits and make phone calls
and things like that. Why don't our mental health program have that? Why
isn't there interventions in the schools? Why is there not support workers
going out? Why isn't there more awareness in the community? (YP5102)
Yeah, I think it’s tough sometimes. On one hand you have to go and make a
choice to seek some help… and that’s pretty confronting, especially as a
younger person. But I think sometimes we hear that, whether it’s sport or
whether it’s in the school setting, having those – maybe it’s not a
psychologist or a specific health worker but those kind of mixed in services.
(YP5105)
5.3.7 Person-centered care is what we want
Once engaged with a mainstream SEWB service, participants critiqued aspects of service
delivery. Experiences of feeling isolated and uncomfortable inside mainstream SEWB
services, even before meeting the clinician, was an experience promoted as needing change:
No, they don’t really check up on you. Or even if you’re sitting there waiting for the doctors, they don’t really say anything. They just sit and wait until the doctors sing out to us. (YP2105)
Think just be there for everyone. Check up on, I reckon. Tell them, are you okay? If they say they okay, no serious, are you okay? About not asking are you just okay, they asking you tell me, are you okay? Speak your mind. That’s what we – yeah, I reckon. (YP2105)
Another critique of mainstream SEWB services was based on experiences of feeling rushed through the assessment phase:
I think definitely, yeah, like I said, more assessments. Sit down, take more time with them as well. Delve into what the actual problem is. There's always
76
a problem as to why someone is the way they are. Actually, yeah, take time. Take time. Because they might not open up the first time, but they might eventually open up to you, and you'll delve into that problem. (YP2101)
5.3.8 Holistic services are desired
Most participants desired SEWB service options that offered alternatives to clinical, or
Western biomedical models. However, those models of SEWB programs were limited:
Yep, because up here, there’s not many programs for younger than my age and I’m 24. Name one program I’ve come to here this week, any day. I’ll have a day off it. There’s not one program I can come, and I don’t have children but why should I have to have children to come to a program? (YP2104)
I reckon. I haven’t heard anything about for younger ones. I reckon it would be good for something to get put on for all the young fellas that come and do something. Whether they want like put up and if they say – I wouldn’t even have a clue what they want. Or have something running for them to get them out of their – get out of that mental health stage. (YP2105)
Participants also expressed suggestions for whole of community programs that sought to
mitigate community level negative factors impacting on SEWB:
A lot of the boys are real angry like, and they need something to take their anger out instead of doing silly things you know like even set up a boxing thing, you know, [for them to] get in and take the [ring around]. (YP2102)
Yeah, no I'd definitely - if I had a magic wand, I'd do a rehab centre with more beds. I do know a couple of people that - they go that way and then there's no beds here in (community), and then they just continue down that sad path, I guess. (YP5104)
It’d be about bringing the whole community together and making sure it’s all right for everyone. Not just for one person. Making sure that it’s all right to knock down barriers with everyone. (YP2104)
77
5.3.9 The Emergency Department (ED) needs to change, it’s a crisis driven system
Aboriginal young people described experiences of distressing and confusing presentations
to the ED. In explaining the lack of alternative options of care focused on early intervention,
the crisis driven mainstream system has embedded help seeking behaviors of participants to
more frequently enter the ED setting when severely overwhelmed with SEWB issues.
A key frustration reported with the mainstream SEWB system, that it was only reactive to
Aboriginal young people’s actions, rather than being responsive to their SEWB needs, was
identified in one participant’s experience:
Well there’s no supports really available unless you go get locked up or go get a criminal activity. That’s the only support that you have, is through juvenile justice. They’re the only people that can support anyone in my eyes. (YP2104)
Participants raised concerns for younger, emerging generations of Aboriginal peoples
potentially needing SEWB services. Insights into the complex environments Aboriginal young
people encounter when confronting SEWB help seeking, in the community context, were
identified. Concerningly, the reality of the mainstream’s failure to fulfill its purpose was
stated with clear frustrations:
Like the young girls now, a lot of them get into trouble now because they’re finding that it’s easier to go get in trouble and get help that way than asking their own family and people that they know. You can’t walk up to your local organisation and say oh, I’m struggling, I need help. (YP2104)
Yeah. Because if - the way I see it is, if a kid goes in and they think I'm going to go in here, I'm going to walk out better, and then it just backfires on them and they walk and they're like; didn't work, don't want to do it. It would be hard for them to pick up again. They'd be like; what's the point it didn't work the first time. (YP5102)
Why should I have to go through Domestic Violence to come to a [SEWB] program? (YP2104)
78
Sh#t. It’s sh#t. Unless you’re section 34, it’s f###ing sh#t. Section 32 or whatever it is. It’s f###ing sh#t. It’s sh#t. You don’t get nothing. You don’t get nothing. (YP2104)
5.3.10 Inadequate SEWB and mental health assessment in the emergency department
Emergency departments (EDs) were critiqued for the little attention given to assessment
procedures. One female participant identified that the first important step after presenting
to the ED was to have an appropriate assessment conducted with adequate follow up,
which was not her experience:
I think they need to do more assessments on people who come in, and actually assess them further. If someone's genuinely wanting help, let them have the help. I feel it's just completely - you're turned away there… (YP2101)
The SEWB assessments experienced in EDs were fast, abrupt and rushed, leaving participants with a sense of being pushed “straight out the door”:
So, other services I've tried to - I've been to psychiatrists, I've been to psychologists. They just seem to tell me that it's all in your head. There's not really much support. I've had assessments from the mental health team at Liverpool Hospital, and they just did a quick assessment. It took them like 10 minutes, and they just said, there's no issues. That was it, straight out the door. I've never heard boo from them again. (YP2101)
They just said, there's nothing wrong with you, after ten minutes later, and out the door. That was the assessment. I only got that assessment because I begged - I was screaming, begging down the phone for someone to do something. That's all they gave me, was 10 minutes, and to say I didn't have a problem. YP2101)
Definitely with the assessment side of things, for mental health. They barely even let someone [touch foot] to get an assessment. I think the only way you'll really get an assessment is if you're - if I guess police pick you up, or something like that, where you're deliberately referred. Whereas, I was like a self-referral. I wanted help, didn't even give it to me. Yeah. (YP2101)
79
5.3.11 Being taken seriously in the Emergency Department
Presenting at the ED for SEWB was conveyed as traumatic and discouraging. Sensing that
SEWB issues being experienced were not considered to be legitimate by ED staff was
difficult for one participant. In hope of seeing a mental health professional, the lack of
appropriate expertise was a further burden to the situation:
I think they thought I was going crazy. I tried to explain to them, if I'm noticing something's wrong, then something's wrong. It's hard for someone to admit something's wrong. I think they, yeah, just thought I was just another loopy, and off I go… (YP2101)
I think they need to take mental health more seriously. I think that it's - I didn't even get seen by mental health when I checked into emergency. They did not even come past. They did not even see me. I just was seen by a normal doctor who was pretty much telling me, it's all in my head. I did not even touch base with someone from mental health, at all. That's what I really wanted. Yeah, and didn't even get close. (YP2101)
For a young person presenting at the ED, details were explained on how confusing it was to
be following the apparent guidelines, to end up with inaction:
There's posters everywhere saying, ask for help, ask for help, ask for help. I was screaming that at the doctors. I said, there's all this stigma to get help and ask for help, but how do you access it? It was just lies after lies. (YP2101)
Unfortunately, even when an individual has been successful in reaching the intended mental
health facility of the hospital, the impact on the situation was reportedly minimal:
I've tried to access mental health through - I've been checked in for panic attacks at the emergency, they've shipped me off to the mental health facility in the hospital. They deem that there's nothing wrong, so they just ship you home. There is really not much support. (YP2101)
80
In keeping with views expressed about accessing SEWB care through mainstream services in
general, many participants explained they could only access support through ED if they were
experiencing a crisis. If ED did not assess them as being in crisis they experienced being
shuffled around and turned away:
It's - the only way I think you can get help is if you go absolutely crazy and the police are called in, you're shipped in there, or something. It's the only way you're going to get help. I didn't want to get to that stage, but it was crossing my mind, maybe I have to do something stupid to get help. Because no one would give me help. I tried every phone number, every avenue, emergency, every mental health facility. Turned away. Yeah. (YP 2101)
5.3.12 More SEWB and mental health supports are needed in the emergency department
Repeated negative experiences at the ED provided scope for participants to directly call for
additional and alternative advocacy support at this level:
Yeah, I think if there was maybe some kind of counsellor to help give you a voice, because I just feel - yeah, they just think, it's a crazy person. There's no one there to back you up, and say hey, something's not right. You know? Yeah, definitely. (YP2101)
Of concern, was the identification of the shared experience of reduced access for other
young (non-Indigenous) people. Captured in the following quote, ED SEWB services are
“near impossible” to access and positioned as representative of enacting internalised
racism, “…if they [non-Indigenous young people] can’t access it, how are we (Aboriginal)
going to access it?”:
Positive? None. None at all, to be honest. Negative, it's all negative really. I couldn't - in the emergency department, you do not get to see someone from mental health. Normally, there's one - there's at least someone there from mental health. Do not even get close to seeing them. I also have a partner who was admitted, same kind of thing, mental health. He had a severe panic attack. He didn't even get to touch base with mental health, and he's not
81
even Aboriginal. So, if they can't access it, how are we going to access it? It's near impossible. You've pretty much got to be, I think, on a court order or something to get the service. (YP2101)
5.4 : Theme 3- Cultural Safety and SEWB services
5.4.1 Culturally relevant SEWB care
Aboriginal young people reported that they required SEWB options of care tailored
specifically to meet the needs of Aboriginal young people. Experiences of culturally relevant
SEWB care were appealing and were also considered to be spiritually supportive and
transformative. Success factors for culturally engaged SEWB care noted by participants
included involving Elders, community leaders, and connecting with traditional land and
Country. Suggestions made were reflections of personal experiences:
…like taking the young black fellas out bush and that you know, and just take them camping and talking more, getting it out of them you know. Asking them questions, you know, and how they can - how they would want it to change because you got to talk to the young fellas you know. There are smart ones out - like they’re smart bro you know, they’re not silly, and they know what they want. They [don't] know what to do, you know. Yeah. (YP2102)
Elders, people that's been through the same sort of thing and being able to talk and sit around a campfire and just [mad] yarn, you know like tell ‘em yarns… Because I know that helped me a lot too - spiritual, spiritually you know culturally, it was the maddest feeling I’ve ever felt. (YP2102)
They monitor him. Well not monitor him but they check up on him. They say oh, come on, we’ll take you out. We’ll have a yarn to you. What do you want to do? We’ll go out and do some bush lessons or something like that. They get a young people program together, they take them out. They were only out there the other week, they took them out to Wedderburn, and they all go carve weapons and that. (YP2104)
82
5.4.2 ACCHS = Culturally appropriate SEWB services
Finding comfort in being surrounded by other Aboriginal people at a SEWB service was
commonly reported across participant experiences with ACCHS SEWB services. Participants
expressed that ACCHS SEWB services related to the personal problems and the contexts
Aboriginal young people encounter, while mainstream SEWB services were juxtaposed as
lacking this understanding:
I think that the services here is more obviously tailored for Aboriginal or Torres Strait Islander people, which gives you more of a comfort feeling. Whereas a lot of other doctors, they kind of don't understand that Aboriginal people have different problems and have different needs that aren't met. Whereas you guys, yeah, seem to meet it a bit more. (YP2101)
Being around – like for me, just being around more Aboriginal people made me feel a bit better. (YP5105)
I think it's just you guys understand the needs of what young Aboriginal people are wanting, whereas mainstream it's just - you're just like a number. There's no real person-centred care. Whereas out here, everyone's treated with respect, courtesy. I find that here you guys just understand a whole lot more than someone who's just from another health facility by itself. Yeah. (YP2101)
5.4.3 Mainstream SEWB system & services – insufficient for Aboriginal needs, failing to cater for Aboriginal cultural safety
Enhanced patient centred SEWB care in the mainstream setting was desired by participants.
Mistrust in the commitment of SEWB mainstream services to properly cater for Aboriginal
young people was of concern. Interestingly, participants were noting that even minor
adaptations to mainstream SEWB service delivery, like “talking with the person, and
explaining things to them nice and clearly”, would have potential to boost the effectiveness
of participant experiences:
83
I think talking with the person and explaining things to them nice and clearly. Because I know with anxiety, you can get quite worked up and it just goes through one ear and out the other. I think just having the comfort zone and knowing that you're going to be turned away. My attitude going into emergency was shocking, because I knew it was just going to be the same thing. Here's a Valium, out the door you go for the night. That's that. It doesn't solve the problem. There's obviously an underlying issue, and it never gets delved into. Yeah. (YP2101)
Aspects of mainstream SEWB service design and delivery were perceived as culturally
inappropriate. One female participant expressed an uncomfortable occurrence where she
was referred to an older male clinician in the mainstream SEWB service delivery. In some
cases, this would be perceived as culturally inappropriate in an Aboriginal context, and
might be deemed as taboo:
She was happy with the process at (the ACCHS), but to be referred out and then go see, well - old white man; she didn't like at all… It scared her and she didn't want to talk to this person she didn't know. Yeah. It's just hard. You kind of sit back and go, well how can I help her? (YP5102)
Another example of culturally disengaged mainstream SEWB service design and delivery was
conveyed by a participant who experienced an uneasiness of being in a clinical setting.
Importantly, the participant not only described the negative experience but also suggested
possible solutions:
That’s nerve-racking for - especially Aboriginals too because you're stuck inside [the walls]. To be able to, maybe for - to be able to talk freely, to be right you know outside…somewhere other than just sitting inside a room, you know, and just having the walls to look at, being nervous about. To be able to get out maybe go for a drive, pull up at a park, and just have a mad yarn. Get out and that, yeah. (YP2102)
For black fellas you know, if you were to take them out to the bush, with the Elders and that, and learn ‘em a few things like… Teach em’. It’s gonna open up - it makes you think different. It's happened to me when I went to my
84
home to my uncle. He spoke and I spoke to him. It was that easy. I couldn’t talk to no-one like I did him, you know. He helped me a lot too. But other than that, I see with the young fellas when they go on camps and that with that, they only went on a camp not long ago. (YP2102)
And that’s what I reckon like that does will help a lot of people going through mental health. Aboriginals you know to be able to go back to country with their mob. (YP2102)
An inability to genuinely understand the needs of Aboriginal young people who sought help,
and not having adequate cultural expertise, were experienced by multiple participants. One
participant viewed this gap as a major underlying concern for the mainstream SEWB system:
It's hard with non-Aboriginal organisations that they don't have that culture awareness about them as well. (YP5102)
Aboriginality checks and Aboriginal health worker support, were seen as an important first
step in understanding and enacting culturally safe approaches to provision of care, and were
noted as absent in the experience of mainstream SEWB help seeking for one participant:
I say - I say to them - I never get any liaison officer, nothing. Nothing comes past. Nothing to do with Aboriginality, no. Yeah. (YP2101)
Participant experiences highlighted that a lack of cultural awareness negatively impacts the
capacity to resonate with Aboriginal young people accessing SEWB services. One participant
was offered advice that contradicted cultural norms, and this became a barrier for her
engaging with the SEWB service. The advice given to her did not align with Aboriginal family
dynamics and demonstrated a lack of cultural understanding and insight:
Yeah but she kept turning around and saying to me, she goes oh, you got to think of you, you got to think of you. But you just come from working at a black organisation, surely you should know you can’t be just about you coming from a black family. (YP2104)
85
Another similar experience occurred on a separate occasion for one participant, who
insisted that the current structure of mainstream SEWB systems made it simply easier to
just seek SEWB help solely within an Aboriginal organisation:
Well like (the Aboriginal ACCHS staff member) said, the cultural awareness thing… I just - whenever I went to go see the counsellor, I didn't feel like she saw my point of view. ..... because she didn't have that. But whereas if you went to (the ACCHS) then, I don't know, I just feel like they'd understand me more and I'd be more comfortable. Yeah. It's not easy going from one place to a new place. (YP5102)
5.5 : Theme 4- Service Integration
5.5.1 SEWB services and systems need to work together
Participants voiced experiences of SEWB service systems (both between mainstream and
ACCHS and within mainstream itself) that lacked integration and continuity of care. At the
ED, concerns were particularly strong:
There's no aftercare of what to do. No, there's nothing. It's just, here's a Valium to calm me down, and you're out the door. There's no follow-ups, there's no nothing really. Yeah, you're on your own. (YP2101)
Yeah, no, there was no support at all. They gave me a card that was meant to be a number to call to book an appointment, emergency, a proper appointment, and they just palmed me off with a whole lot of information to the suicide hotlines. I got home and called them, and they were like, this isn't an appointment number, it's suicide hotline. I was like, that's not what I want. (YP2101)
Negative experiences of lack of cohesion with referrals highly discouraged some participants
from SEWB help-seeking. Given SEWB help seeking for a young Aboriginal person can be
challenging, the experience of services lacking continuity was identified as a true barrier:
86
I think it would be hard. Very hard. But if kids are getting referred out to community health or Headspace and things like that and then they don't go to their appointments, I think it would be very hard for them to even pick up again or even try another service. (YP5102)
It was the same process all over again, really. They'd sit there and be like; well, do you want to go and see someone else; do you want medication; do you want to - they just. You go to one place, it doesn't work; you go back, they try to send you off to another place and it's just going to be the same thing. (YP5102)
Cycles where negative experiences involving uncertainty around continuity of care and
having inadequate supports when navigating the SEWB system were highlighted as barriers.
Adding more Aboriginal health workers or liaison officers, however, was offered by
participants as a suggestion for adding valuable support that could transform SEWB
integration and delivery:
Yeah, see I've, yeah, I think I've been referred out once and it was a bit rough because they didn't communicate times and appointments and things like that. I just feel like, it's a bit hard to ask, but to have maybe an Aboriginal representative at each place that just - if they get a referral from an Aboriginal and Torres Strait Islander centre that they can communicate. I don't know. That's what I mean, it's a bit hard to ask to have that everywhere. (YP5102)
But if they have the mental health workers supporting the young people, giving them calls, like following up; have you gone for your appointment, would you like me to go with you to your appointment and things like that would help a lot of kids transition from (the ACCHS) to mainstream. (YP5102)
5.5.2 ACCHS make efforts to enhance SEWB service integration for clients
Feeling comfortable accessing an ACCHS, inclusive of doctors and other health workers who
were able to facilitate appropriate, supportive referrals, was valued. Longstanding positive
ACCHS-reputations, familiarity with employees, willingness to facilitate liaison with
87
mainstream SEWB services, and humanity in SEWB service delivery were identified as
positive, enabling young Aboriginal people to access SEWB services:
Because (the ACCHS) been here for so long and everyone knows (the ACCHS).… They feel comfortable coming down to the doctors and the majority of the workers are from this community, so they see it's our - they know we're humans, we're not robots and everything like that and they're comfortable to come to us. (YP5102)
5.6 Chapter summary
Results from yarning with Aboriginal young people provide valuable insights into the current
SEWB system. Not only did Aboriginal young people provide insights into positive and
negative considerations of SEWB systems, but it is also evident that Aboriginal young people
are willing and capable to provide meaningful ideas and solutions that have the potential to
counter existing failures. Greater awareness, information, and supports on available SEWB
services are required. Importantly, this guidance needs to incorporate foundational
information of what is involved in seeking SEWB care, differences between forms of care,
and what is best suited for different circumstances. Accessing services also requires
enhanced supports. While ACCHSs were positioned as leading the delivery of alternative,
more holistic models of care, mainstream services, particularly the ED, were extremely
difficult to access. Holistic and multifaceted SEWB services are needed, and from the
position of Aboriginal young people, culturally and spiritually relevant options of care should
be increased for SEWB care experiences to improve. During the help seeking process and in
between provision of care, directed efforts to help Aboriginal young people better
understand and navigate the system is fundamental to improve service effectiveness, trust,
and continuity.
88
Chapter 6: Discussion and conclusion
I think they need to take mental health more seriously. (YP2101)
Asking them questions, you know, … how they would want it to change because you got to talk to the young fellas you know. There are smart ones out - like they’re smart bro you know, they’re not silly, and they know what they want. (YP2102)
…if I had a magic wand…(YP5104)
6.1 Introduction
This research is part of a larger body of research being done by the Study of Environment on
Aboriginal Resilience and Child Health (SEARCH) team in partnership with several Aboriginal
Community Controlled Health Services (ACCHS) in NSW, Australia. In chapter two, I
presented a scoping and synthesis of current contextual factors, current SEWB-related
literature and I provided a snapshot of SEWB data. In chapter three I explored the related
SEWB policy environment. In that chapter I highlighted the range of policy changes and
strategic mental health and social and emotional wellbeing national plans that have
emerged, with a greater Aboriginal and Torres Strait Islander focus (Department of Health
and Ageing, 2013a; Department of Health and Ageing, 2013b; Commonwealth of Australia,
2009; Commonwealth of Australia, 2017; COAG, 2006; 2014; Australian Health Ministers,
1998; Australian Health Ministers, 2003; National Aboriginal Health Strategy Working Party,
1989). Those policies and wellbeing plans set commitments to improve health and wellbeing
outcomes for Aboriginal and Torres Strait Islander peoples, with some specifically focusing
on the needs of young people. However, despite developments in structural and systemic
planning Aboriginal young people in this study suggested there is still much work to be
done.
89
The aims of this research were to (i) privilege the voices, experiences and perspectives of
Aboriginal and Torres Strait Islander young people who use mental health/SEWB services
and systems in New South Wales; (ii) establish a consumer perspective on how current
mental health/social and emotional wellbeing services and systems can build upon current
strengths and successes, and (iii) preview suggestions for change by positioning the voices
of Aboriginal and Torres Strait Islander young people as experts on their own SEWB service
needs.
To achieve that work I undertook a qualitative study to investigate the lived experiences of
Aboriginal young people who access SEWB services and systems in NSW. Their data, in
chapter five, highlighted changes needed in early SEWB intervention and highlighted a need
to increase awareness of the availability of SEWB services. Their data shows a need for
better SEWB service integration and for reconsidering how SEWB services can be accessed
by young people. Importantly, they noted that SEWB services have enormous potential to
improve by increasing their cultural safety and increasing service engagement with culture.
The findings of this research (chapter five) and this discussion and conclusion chapter
(chapter six) extends an opportunity to SEWB policy makers, service providers and systems
to engage with current insights from Aboriginal and Torres Strait Islander young consumers,
and further offers scope for reconsidering services, policies and systems to enhance SEWB
service experiences for Aboriginal and Torres Strait Islander young peoples.
6.2 Building on the Mental Health and Social and Emotional Wellbeing Framework
Of particular importance to this research, the Mental Health and Social and Emotional
Wellbeing Framework (‘the Framework’) has a vision “For Aboriginal and Torres Strait
90
Islander people, families and communities to achieve and sustain the highest attainable
standard of SEWB and mental health supported by mental health and related services that
are effective, high quality, clinically and culturally appropriate, and affordable” (Department
of Prime Minister and Cabinet, 2017, p. 14). To achieve this vision the Framework needs to
enact several key foundational concepts that are deemed to have the capacity to
“fundamentally shift the way mental health programs and services are delivered for
Aboriginal and Torres Strait Islander peoples” (Department of Prime Minister and
Cabinet,2017, p. 12). These foundation blocks call for Aboriginal and Torres Strait Islander
leadership and partnership in the planning, delivery and evaluation of services and
programs, an understanding of the social determinants of mental health (Osbourne, Baum,
& Brown, 2013), the addressing of racism (Department of Health and Ageing, 2013a;
Department of the Prime Minister and Cabinet, 2017; Szoke, 2012), using person-centred
care (Department of Health, 2015), integrated approaches, trauma-informed care (Atkinson,
2013), culturally appropriate and affordable care (Bainbridge, McCalman, Clifford, & Tsey,
2015), clinically appropriate care (AIHW, 2015) and a greater focus on children and young
people. The latter is of particular significance to this research.
While the Framework suggests that focusing on mental health and social emotional
wellbeing in early life is “an important preventative population health measure”
(Department of Prime Minister and Cabinet,2017, p. 13), without research that utilizes
insights about what works or what is needed in SEWB service delivery, from an Aboriginal
and Torres Strait Islander point of view, inefficient SEWB service provisions will continue.
Williamson et al. (2010) concluded that minimal community knowledge exists on SEWB
concepts and contributing factors to SEWB, highlighting that this lack of knowledge
91
contributes to a lack of understanding of what makes an effective SEWB service. Priest et al.
(2012a; 2012b) emphasise the disproportionate focus on physical health research and
suggest that Aboriginal culture and health narratives need attention if social determinant
inequalities of health and wellbeing are to improve. Greater insight and understandings of
the lived experiences of SEWB and SEWB service provision of Aboriginal and Torres Strait
Islander young peoples has been identified as a priority for research that focuses on SEWB
trajectories (Gubhaju et al., 2019; Kalucy et al., 2019; Kilian & Williamson, 2018). Much of
the recent work on exploring SEWB trajectories into SEWB services align with foundational
work that positions Aboriginal and Torres Strait Islander young peoples’ lived experiences of
SEWB service delivery as pivotal to making effective policy and practice reform (Blignault,
Haswell, & Pulver, 2016; Dudgeon et al., 2017; Haswell, Blignault, Fitzpatrick, & Jackson
Pulver, 2013; Kelly, Dudgeon, Gee, & Glaskin, 2009).
Urgency is stressed in both reports that regardless of future progress made, underlying
social determinant inequalities will overpower the potential that change promises to deliver
(Haswell et al., 2013; Kelly et al., 2009). Underpinning hardships that social and emotional
services endure in countering poor outcomes, is community level inequality. Aboriginal
young people share socio-cultural contexts where both objective and subjective life
stressors cohabitate. Objectively the SEWB health system must understand how to
approach culturally appropriate and impactful provision of care, subjectively the voices of
Aboriginal young people through research can share the knowledge that helps this to
happen. Available social determinant focused data evaluations exist for Aboriginal young
people in Australia. If we detach the social determinants from understanding the current
SEWB context, the reforms soon to be made will fail to meet their purpose.
92
6.3 Shifting the deficit discourse and engaging with strengths
As a young Koori researcher, I uphold a focus on finding ways of shifting the deficit
discourse9 that is frequently used to shape narratives about Aboriginal and Torres Strait
Islander young people’s health and wellbeing. Deficit discourse has potential to position
challenges or problems as being the responsibility of individuals, rather than considering the
wider socio-political and structural determinants of health and wellbeing. The impact of
deficit discourse on health and wellbeing has been noted by Halpern (2015), while Fogarty
et al. (2018) state that “continual reporting of negative stereotypes and prevalence rates
actually reinforces undesired behaviour” (p. vi). While this research acknowledges that
SEWB outcomes remain poorer for Aboriginal and Torres Strait Islander young people than
for their non-Indigenous counterparts (Young et al., 2017), maintaining a focus on deficit
discourse prohibits opportunities to explore strengths and possibilities for making change to
wellbeing outcomes.
This research sought to engage voices of Aboriginal and Torres Strait Islander young people,
to provide space for their lived experiences and ideas to be heard and valued and to
position those lived experiences within a positive, solutions-focused way of exploring SEWB
and service delivery. In essence, the research embodied what Fogarty et al. (2018) define as
a strengths based approach; research that challenges deficit thinking and narratives around
Aboriginal and Torres Strait Islander young people and SEWB, and, following in the footsteps
of leading work in strengths based approaches (Askew et al., 2020; Dudgeon et al., 2020;
Dudgeon, Bray, Walker, & Darlaston-Jones, 2020; Milroy et al., 2017) sought to invest in
9 Deficit discourse is defined here as a narrative that represents a cohort of people in terms of deficiency, failure or lack.
93
possibilities for systems and service change, as described directly through the insight, lived
experiences and ideas of Aboriginal and Torres Strait Islander young people.
While my findings do highlight multiple examples of negative engagements with the SEWB
system, as experienced by the young Aboriginal study participants, they also offer an
important, solutions-focused narrative. Being positioned as experts in the room, the young
Aboriginal study participants were empowered to think deeply about what works for them
in the SEWB sector and make multiple suggestions for strategic actions that have potential
to create transformational change. All participants drew on a strengths-based approach
and adopted critical strategic thinking that resulted in offering change-opportunities to
SEWB policy makers and service providers. The following section captures those key
messages, providing four opportunities and multiple strategic actions.
6.4 : Opportunity 1 – Firmly ground Social and Emotional Wellbeing Services in culture
At the collective level, our Aboriginal and Torres Strait Islander communities are
interconnected through respecting Country, finding wellbeing and health through strong
family and kinship relations, and respecting cultural and spiritual understandings of the
world. Cultural foundations that pre-date colonial invasion and society remain as inherent
elements of modern Aboriginal and Torres Strait Islander culture. Adhering to life within
cultural beliefs has shaped, and continues to shape, components of health and wellbeing for
Aboriginal and Torres Strait Islander peoples. Positive Aboriginal SEWB requires individual
autonomy to engage with intersections of life, culture, and spirituality, allowing a flow on
effect to SEWB at a community level SEWB (Brockman & Dudgeon, 2020; Calma, Dudgeon,
94
& Bray, 2017; Dudgeon et al., 2017; Dudgeon et al., 2014). Culturally appropriate provision
and experiences of SEWB services enable significantly more successful engagement for
Aboriginal people. Feeling comfortable attending services, having an ability to resonate with
family, community, and cultural dynamics as intertwined social influences on SEWB service
usage, culturally driven care involving culturally relevant methods of early interventions,
and having Aboriginal SEWB health workers for supports were factors identified as
beneficial to feeling culturally safe. Many of these factors were said to be features of
ACCHSs, however current approaches and structures of the mainstream system seemed to
be failing Aboriginal young people’s needs.
6.4.1 Strategic action (i) Engage Culture, spirit and spirituality
Central to positive SEWB is the inclusion of the role of spirituality, positioning traditional
healers and healing methods at the core of achieving positive SEWB (Dudgeon et al., 2014;
Grieves, 2009). Engaging Culture, spirit and spiritualty has long provided positive emotional
support, as have the use of healing songs and use of objects with healing powers (Maher,
1999, p. 233). The successful work of traditional healers in the Wundargoodie Aboriginal
Youth and Community Wellbeing Programme was evaluated by Drew (2015). Recognising
the traditional strengths of Aboriginal and Torres Strait Islander health and wellbeing, the
importance of underlying values of Aboriginal and Torres Strait Islander culture and health,
Drew asserts “Collective health has particular resonance for Aboriginal people because it
addresses the importance of social justice for wellness, which is not afforded sufficient
attention in non-Aboriginal society as a social and cultural determinant of health” (2015, p.
621).
95
Ngangkari, a Pitjantjatjara word used to name Aboriginal spiritual healers across parts of
Australia, have been identified as crucial to the growing Aboriginal SEWB movement
(Burbidge, 2017; Hawthorne, 2018; Parker, 2013; Parter, Wilson, & Hartz, 2019). Working
with traditional medicine practices in a culturally appropriate way, Ngangkari provide
remedy for SEWB issues through spiritual realignments and use of traditional healing
practices. Both male and female Ngangkari hold gendered roles of healing, signifying
inclusive and promising community level opportunities for culturally appropriate
engagement with SEWB care (Dudgeon & Bray, 2018; Parter et al., 2019). Ngangkari work,
although often focused on the SEWB needs of an individual, also engages with the external
factors contributing to any individual conditions. This practice respects the holistic
understanding of Aboriginal and Torres Strait Islander health and wellbeing and recognises
the relationships between the health and wellbeing on individuals, communities, culture
and Country. These connections are important to contemporary SEWB service delivery, as
they remain the foundation of SEWB from an Aboriginal and Torres Strait Islander
perspective (Sherwood, 2013; Sherwood & Edwards, 2006). A practical example of how to
engage SEWB services with culture, spirit and spirituality was given by one particular young
Aboriginal participant who suggested SEWB services work with Elders, providing time
around a fire:
Elders, people that's been through the same sort of thing and being able to talk and sit around a campfire and just [mad] yarn, you know like tell ‘em yarns… Because I know that helped me a lot too - spiritual, spiritually you know culturally, it was the maddest feeling I’ve ever felt. (YP2102)
96
6.4.2 Strategic action (ii) Engage ongoing connections to Country
Culturally, Aboriginal people share connection to identity through traditional Country,
nation group, kinship relations, and connections to community. Developed and shared
through many generations, traditional knowledge continues to shape modern life through
lived experience of interconnected natural environments, and community contexts
continuing subjective cultural developments.
Benefits of both traditional and ongoing connection to Country have been well documented
in research (Burgess et al., 2009; Rigney & Hemming, 2014; Townsend, Phillips, & Aldous,
2009). Traditional lifestyles flourished on the availability of local flora and fauna. This
connection to health and wellbeing through the surrounding environment has always been
more than physical. Deepened relationships with environmental systems fostered spiritual
beliefs respective of connections with land, sea, and environment. Colonisation
compounded by modernisation has disrupted these social structures immensely and is
deepened with the ongoing detriments of stolen generations. Although, strengths of
traditional lifestyles that existed in those pre-colonial socio-cultural systems that more
freely valued connection to the environment, positively enabled cohesive community
dynamics. Aboriginal people continue to live well through strengths of traditional lifestyles
in our modern age. This is echoed by a young participant who suggested SEWB services
engage Elders and community members to take Aboriginal young people on Country as part
of SEWB services. Being an Aboriginal young person, having an awareness of the benefits of
culturally informed early intervention and SEWB, provided sound evidence for a practical
suggestion for SEWB service delivery change:
For black fellas you know, if you were to take them out to the bush, with the Elders and that, and learn ‘em a few things like… Teach em’. It’s gonna open
97
up - it makes you think different. It's happened to me when I went to my home to my uncle. He spoke and I spoke to him. It was that easy. I couldn’t talk to no-one like I did him, you know. He helped me a lot too….going back to country with their mob. (YP2102)
O'Brien (2005) explored issues that shaped Aboriginal young people’s SEWB in one New
South Wales Aboriginal community and suggested that traditional values continue to inform
the experience of Aboriginal young people’s SEWB, “Aboriginal mental health and mental
illness appear to be inextricably tied to culture, kinship and community, as well as issues
surrounding Aboriginal cultural identity and spirituality” (p. 19). Similarly, Warburton and
Chambers (2007) support how structures of traditional social and community lifestyles
translate into subjective social and emotional cultural outcomes, explaining that, “This
family or community focus is related to the holistic nature of Aboriginal and Torres Strait
Islander ideologies which, unlike Western thought, does not emphasise individualism, but
the interconnectedness of all aspects of life” (p.4). Socially, the examples discussed show
how components and beliefs of traditional culture favour community connection that
support individual wellbeing towards community wellbeing, attachment to nature as a form
of sustainability and vitality (Biddle & Swee, 2012), and the ability to engage spiritually with
the surrounding environment and histories of ancestors past (Warburton & Chambers,
2007).
6.4.3 Strategic action (iii) Engage family and community level support networks
Young Aboriginal participants suggested that family members and extended relatives being
involved in SEWB care for Aboriginal young people improved Aboriginal young people’s
wellbeing and experiences of SEWB services. While Williamson et al. (2010) found that
family members should be included in processes of seeking help, working alongside services
98
and clinicians, Mohajer, Bessarab, and Earnest (2009) reported that family members were
favoured as initial contacts for support regardless of other persons and health workers
being available. In this example itself, evidence can suggest that through properly
understanding where help seeking and comfort rests for Aboriginal young people when
approaching SEWB issues, manageable and reasonably simple adaptations could be
embedded without systemic level reforms. One young Aboriginal participant affirmed these
findings by suggesting that SEWB service delivery planning should “…be about bringing the
whole community together and making sure it’s all right for everyone. Not just for one
person” (YP2104). Hinton, Kavanagh, Barclay, Chenhall, and Nagel (2015) propose that in
addition to family member involvement, Elders and cultural activities can be embedded
when improving service utilisation and care, enabling cooperative community environments
to better reflect holistic service desires of Aboriginal young people social and emotional
wellbeing. Community level health engagement and encouragement opportunities arise in
this context to be culturally informed and respected as co-delivery of differed approaches to
health occur.
Not only were Aboriginal Elders suggested to be included in SEWB service delivery, so too
were other role models, with one young Aboriginal person stating “… [Aboriginal role
models] come from the roots, the same roots as the boys” (YP2104).
6.4.4 Strategic action (iv) Keep building up Aboriginal Community Controlled Health Services
Aboriginal Community Controlled Health Services (ACCHS) were considered by all young
Aboriginal participants to be the foundational models of culturally safe SEWB care.
99
Community driven, ACCHS remain the leaders of community driven healthcare, according to
the lived experiences of the young Aboriginal participants:
I think it's just you guys understand the needs of what young Aboriginal people are wanting, whereas mainstream it's just - you're just like a number. There's no real person-centred care. Whereas out here, everyone's treated with respect, courtesy. I find that here you guys just understand a whole lot more than someone who's just from another health facility by itself. Yeah. (YP2101)
Culturally relevant SEWB service and cultural safety were considered as components that
needed to improve in mainstream services, “‘It's hard with non-Aboriginal organisations
that they don't have that culture awareness about them” (YP51025).
6.4.5 Strategic action (v): More Aboriginal and Torres Strait Islander staff in SEWB services
Young Aboriginal participants advocated for improving cultural safety and culturally relevant
SEWB services by increasing the numbers of Aboriginal and Torres Strait Islander workers in
SEWB services, “Being around – like for me, just being around more Aboriginal people made
me feel a bit better’” (YP5105).
Provision of SEWB care that did have cultural safety embedded within the service’s core was
identified as positive, ‘I think that the services here is more obviously tailored for Aboriginal
or Torres Strait Islander people, which gives you more of a comfort feeling’ (YP2101).
My findings suggest that mainstream services with few Aboriginal staff, particularly those
who also have minimal engagement with Aboriginal clients and community, often struggle
to achieve even a generalised understanding of Aboriginal cultural obligations, yet alone
more specific Aboriginal cultural features. One participant faced a SEWB health professional
who was pushing them to “just think of you” as a way of improving SEWB, a suggestion that
100
the participant decided would not have been suggested by an Aboriginal worker in a “black
organisation [who knows] you can’t be just about you, coming from a black family”
(YP2104). Aboriginal SEWB workers were considered invaluable in SEWB services as they
helped navigate cultural obligations, community dynamics, and were seen as “…someone
there that understands where I’m coming from kind of thing, yeah, that helped” (YP2102).
6.5 : Opportunity 2 - Take time, see us, listen to us- simple consumer-centered SEWB services
Aboriginal young people know what they want from services, and some of those things were
all about person centered care. Small adaptations to some SEWB services were suggested by
young Aboriginal participants, who saw the potential some minimal changes could easily
make on initial SEWB service experience and on the continuity of engagement.
6.5.1 Strategic action (i): Human to human interaction in SEWB service delivery
Feeling like SEWB services and workers see you was important; one participant said “…they
don’t really check up on you. Or even if you’re sitting there waiting for the doctors, they
don’t really say anything. They just sit and wait until the doctors sing out to us” (YP5102).
Personalised service (for example, having an advocate, offering realistic appointment
schedules, and having thorough follow-up procedures) was considered a major enabler of
staying engaged with SEWB services. It was really important to have a friendly face at the
front desk, preferably someone who knew a consumer’s name, or was quick to learn their
name and use it in a welcoming way.
Taking time to engage with a young person, including offering longer appointment times,
was seen as highly significant and lacking in many services, ‘Just taking the time out and
101
actually caring about who you've got in front of you, not trying to rush them out the door’
(YP5104).
6.5.2 Strategic action (ii)- Use clear communication
Participants identified that knowing how to approach and access services could be
challenging. Even when multiple platforms and options of care exist, confusion surrounding
the process of utilising professional care was highlighted by most participants, as highlighted
by YP2102, “If you don’t know where to start, you think like, you know, you're just like,
you’re just not sure, you’re not sure about it. It makes you just not want to get help kind of
thing”.
Aboriginal young people often remain on the fringe of health systems, partially this can be
attributed to ineffective advertisement and promotion of services. Feeling isolated because
of not knowing what services were out there could be resolved, according to the
participants, by being “more clear to people that there is that help there”.
Another important suggestion for change was developing a clear way of communicating
pathways through SEWB services. Several participants spoke of a desire to have information
given to them that stepped them through the whole SEWB service experience, from first
thinking or feeling you might need SEWB support, right through to recovery and
maintenance of wellbeing. A simple communication tool was suggested to have the
potential to reverse the feeling of “Just not knowing what you’re in for… like just not
knowing what’s going to happen and what could happen”. A tool to demystify the SEWB
help seeking process was offered as a considered, practical, contextualized, and simple way
to provide helpful information.
102
In addition to a tool, advertisements that demystified how to find SEWB services, who was
available to see at those services, and what types of care were offered in each place were
suggested as simple but effective strategies for change. Participants suggested more
information needs to be regularly circulating in community, including the use of posters
that “speak” to young Aboriginal people and better use of social media platforms that have
scope to both advertise services and encourage people to build up connections and share
SEWB service experiences.
6.6 : Opportunity 3 - Services working together, are better services
My findings suggest there are not enough SEWB services available to meet the needs of
young Aboriginal people, “there’s not many programs for younger than my age and I’m 24”
(YP2104). Working together was seen by young participants as a simple way of growing the
number of SEWB services. Holistic services that are genuinely appealing, multi-faceted and
working collaboratively, “those kind of mixed in services” (YP 1505), were considered better
SEWB programs.
6.6.1 Strategic action (i) Services should share after care and follow ups
The experience of “no follow ups” from mainstream (ED) SEWB was common in the data.
Increased local planning between SEWB services has potential to share the vital follow up
and after care work that was seen as missing. Mainly after care and follow up service
integration was found to be poor following an episode of care in an ED.
103
6.6.2 Strategic action (ii) – Make better use of Aboriginal health workers or navigators
Several participants suggested that better use of Aboriginal navigators in both ACCHS and
mainstream services when transitioning between services would “help a lot”. Data suggests
that poor communication between services might be improved by a network of Aboriginal
health workers or navigators who could act as consumer advocates within the fragmented
systems “to help give you a voice”, and were considered to be one way to keep young
Aboriginal people engaged in SEWB services.
6.6.3 Strategic action (iii) : SEWB services and schools need to work together
When questioned on what possible early intervention settings could be most successful for
Aboriginal young people, participants commonly believed that schools hold the potential to
be a positive environment that coincides with assisting SEWB care. Programs that encourage
consistency of culture, community, attendance, participation, and education have been
successful in helping to maximise likelihoods of positive SEWB. Participant YP2102
reinforced support for school based early interventions, encouraging the engagement of
youth, social, and health workers to interactively collaborate with school settings to bridge
pathways to care through early intervention through these interlinked provisions of care,
“They should be going into the schools and talking to the schools about that. You know like
talking to the schools about the kids that need extra help because you can tell from the kid
who goes to school and mucks up at school that he’s not having a good feeling outside of
school you know. His routine isn’t good outside of school…”.
104
6.7 : Opportunity 4 - Stop young Aboriginal people from “falling through the cracks”
6.7.1 Strategic action (i) – screen early and do early intervention for SEWB needs
Although research has aimed to improve cultural appropriateness of SEWB screening tools,
screening and early intervention still remains a challenging space, with most Aboriginal
young people in this study in favour of increased, early screening and early intervention. The
findings suggest that early intervention services and approaches to care, were noticeably
absent in both ACCHS and mainstream settings. Introducing early intervention services was
seen as vital to decreasing the current high SEWB needs in young Aboriginal people, by
screening early and providing earlier interventions, rather than waiting until a person
reaches crisis point.
6.7.2 Strategic action (ii) Slow down the time taken for doing an assessment
Findings suggest that assessments done in the EDs were always rushed, and often not done
by a SEWB health professional who has an appropriate level of understanding of Aboriginal
and Torres Strait Islander ways of knowing, being and doing (Sherwood, 2013). Participants
shared a range of rushed assessment experiences, including “It took them like 10 minutes,
and they just said, there's no issues. That was it, straight out the door. I've never heard boo
from them again’” (YP2101), and all advocated for an approach that allowed for the SEWB
health professional to “sit down, take more time”.
105
6.7.3 Strategic action (iii) – Decrease barriers to accessing SEWB services
Access issues are major barriers for Aboriginal young people seeking SEWB care. Physically,
outreach services were identified as positive ways of increasing access to SEWB services, as
not all young people prefer traditionally delivered SEWB care.
Systematically, Aboriginal young people’s perceptions of the existing system are alarming.
Engagement in criminal activity or decreasing one’s wellbeing intentionally are symptoms at
the chronic end of SEWB issues, more importantly, these are desperate attempts to seek
help in local service systems from unsupported Aboriginal young people that are being
unanswered. With service provision, few participants could identify positive examples of
accessibility. Rather, Aboriginal young people tended to share negative experiences of the
ED. Not only does this represent failures and gaps of missing early intervention care across
systems, it solidifies the SEWB context that drives the commonplace need to present to the
ED as an Aboriginal person, usually with more chronic impacts, being at a later stage of
poorer health. Culturally, Aboriginal health workers and Medical Services were viewed as
safe and supportive above all other available options of care. Preference was also given to
SEWB care within ACCHS. Interpersonal interactions were valued by participants.
Welcoming staff, approachable health workers, and person-centred services are elements
that when combined with enough time, were suggested as in need of increased availability
and consistency.
ACCHS provision of outreach SEWB care was considered to bridge the gaps between
transport, educational commitments, personal schedule requirements, and the myriad of
other considerations that may impact on an Aboriginal young person experiencing
106
difficulties with accessing SEWB services. Outreach included being available for drop ins as
well as being able to provide home visits.
Having shorter waiting times, more available appoints and longer service hours were
suggestions made for ACCHS improvement of SEWB service delivery.
6.7.4 Strategic action (iv) change SEWB processes in the EDs
Most young people insisted on making changes to how SEWB services are experienced
when presenting at ED. An important suggestion was to ensure young Aboriginal people
are assessed by SEWB health professionals when they present, with several participants
stating they never saw a SEWB worker at all when in ED.
One participant declared a sense of hopelessness when describing how her partner (non-
Indigenous) “didn’t even get to touch base with mental health”. Her loss of faith in the
system was loudly voiced in a comment that also suggests some levels of systemic racism
“He didn't even get to touch base with mental health, and he's not even Aboriginal. So, if
they can't access it, how are we going to access it?” (YP2101).
Stigma often connected to seeking SEWB support needs to be addressed. Participants
presenting in EDs faced being told “it’s all in my head” or left the ED with a sense that health
professionals “just thought I was another loopy”. Young Aboriginal people noted that “ask
for help” messaging was “just lies after lies” because when they did ask for help, they did
not receive it.
107
6.8 Strengths of this research
This research is grounded in positive, respectful relationship building and nurturing. The
time taken to build and care for the relationships and connection between myself, other
SEARCH researchers, ACCHS and participants was crucial to building a safe research space in
which young Aboriginal and Torres Strait Islander peoples could share their lived
experiences of SEWB services and systems. While my research upheld all Western research
protocols and requirements it also upheld all cultural protocols, and this was essential for
me, as a Koori researcher, for the ACCHS, for other members of the SEARCH Study and for
the participants. Of utmost relevance was the provision for a strengths-based approach that
gathered data that reflected hope, vision and possibilities- through the lived experiences of
young Aboriginal and Torres Strait Islander peoples who rarely have their voices privileged
in research.
6.9 Limitations of this research and ideas for future research
As a qualitative study this research did not seek to generalize but instead to provide a rich,
understanding of the SEWB experiences of young Aboriginal and Torres Strait Islander
peoples who accessed services within the context and geographical boundaries aligned with
several ACCHS in NSW, Australia. Collecting that rich qualitative data required important
relationship building with other members of the SEARCH Study team, with the ACCHS and,
importantly, with the Aboriginal and Torres Strait Islander young people who generously
gave time to this study. If time (and thesis word limits) permitted, additional ACCHS and
participants could have been recruited. However, all relationship building, and recruitment
were guided by local availability and capacity, this ensured that all research and cultural
protocols were upheld and respected at all times. While the findings do provide a rich
108
contextualization of SEWB consumer experiences in some ACCHS and health systems, the
methodology and methods used could be applied to further research that could upscale to
cover a complete local health district region, a state or territory or even be undertaken
nationally. It would be interesting to do a comparative qualitative study that was able to
capture the differences and similarities of Aboriginal and Torres Strait Islander young people
SEWB service experiences across any of those suggested geographies.
6.10 Conclusion
Epistemologically, Aboriginal young people innately possess the best ideas and
understandings of how SEWB services and systems could best serve their needs. True to the
aims of this thesis, Aboriginal young people were asked what was needed to ensure SEWB
services properly address their SEWB needs. This research engaged a yarning method that
empowered the young Aboriginal participants and positioned them as the experts in the
room. As a result, participants freely expressed opinions and ideas about what is currently
working well (and told me why) and equally noted what was not working, suggesting what
needed to change. This research fills a gap in both literature and research methods, as it
centers young Aboriginal SEWB consumers as specialists in SEWB services for young
Aboriginal people. This research provides the SEWB sector with four opportunities, and
suggests 14 collective strategic actions, to make positive changes to the current way SEWB
services are designed and delivered. These opportunities were informed by the voices and
lived experiences of the participating young Aboriginal study participants who generously
shared their lived experiences of the mental health system. Importantly, young Aboriginal
study participants adopted a positivist approach to this research and, while including the
sharing of some negative SEWB service experiences, dominantly focused on providing
109
potentially transformational actions and opportunities to SEWB policy makers and service
providers… and they will closely watch for signs of change.
112
Appendix 1: Sample yarning interview guide
WORKSHOPS AND INTERVIEWS| SAX INSTITUTE 1
Trigger questions for focus groups: ACCHSs and mainstream mental health staff, parent/carers
AND
Interview schedule for one on one interviews with young people
Notes for interviewers/group facilitators:
- We are hoping to keep the group sessions to 90 minutes. Please try to make sure you leave around 10 minutes at the end to say thank you and for people to complete a short survey.
- You don’t need to read out any of the questions, blurbs or prompts as written. Say them in a
way you are comfortable with. Please try and cover all of the content though.
- Please begin the session by introducing yourself and asking everyone else to do the same. You might also like to ask the group to also share something about themselves in relation to ??? (your choice!) to get everyone comfortable and ready to talk.
- Introducing the study: Please thank everyone for making the time to participate a focus
group/interview and introduce the study. You might want to say something like:
Thank you all for coming here today, to share your knowledge and opinions about how the mental health service system in (community x) is working for Aboriginal children and young people – what’s already going well and can be built on, and where there might be opportunities to improve. We are conducting this research in partnership with (X- Aboriginal Community Controlled Health Organisation) and (X Local Health District-LHD) because work we have partnered with (X- Aboriginal Community Controlled Health Organisation on for many years has shown that while most Aboriginal children and adolescents are doing well in terms of social and emotional wellbeing, Aboriginal young people in your area are twice as likely as other children in NSW to have challenges in this area, and much more likely to have challenges so severe they attend the ED for mental health or are hospitalised. Obviously social and emotional wellbeing is complex, but one thing that can help is making sure that there are culturally appropriate services and supports available for children and young people who need them.
So, we have mapped the local mental health service system and are talking to Aboriginal young people who have had recent experience with the local mental health service system, their parents and carers, and (X- Aboriginal Community Controlled Health Organisation and mainstream staff who work in mental health, to get a good birds eye view of how the system currently looks for Aboriginal children and young people. Are there gaps in services? Are there places that are doing an exceptional job of working with Aboriginal clients? Are there key things that could be improved? We will be sharing what we learn with (X- Aboriginal Community Controlled Health Organisation, (X LHD) and other participating agencies so that they can use this information to drive mental health service system improvement. Then we will be monitoring what changes, and what impact the changes have on how the mental health service system works for Aboriginal children and young people in (community x). In this way, together, we will learn more about what works in terms of mental health services for Aboriginal children and young people in your area and hopefully improve the system.
- Participant information sheets and consent forms: Please pass out the information sheets and consent forms and invite people to read and sign. You will already have outlined the study but please point out:
o We expect that the workshops will take approximately 90 minutes to complete.
WORKSHOPS AND INTERVIEWS| SAX INSTITUTE 2
o The workshops will be audio-recorded and professionally transcribed. o If you give us your email address a summary of the main ideas expressed in the
workshops will be sent to you so that you can read and make further comments/clarifications if you want to.
o All aspects of the study, including the results, will be strictly confidential and only the researchers will have access to information on participants.
o Individual participants will not be identifiable in the summary or in any publications arising from this research.
- Please let participants know that there will be a short survey to fill out at the end
1. Before we get to reality, let’s start by brainstorming what a perfect world might look like in terms of services and supports for Aboriginal children and young people’s mental health. What kinds of services and supports would ideally be available for Aboriginal young people in (X community)?
a. Which of these things do you think are already available in your area? b. Which do you think are missing?
2. Thinking about services, programs and supports to either stop Aboriginal children and young people from developing problems with social and emotional wellbeing, or to help treat problems when they are first beginning – do you know of any local services like that? How easy are they to access? PROMPT: What types of services/programs/supports that might help with this are there at (X- Aboriginal Community Controlled Health Organisation, schools, community centres, mainstream services etc? Are there any which are particularly popular/effective? Are these different for infants/primary school aged kids/ adolescents/young adults?
Thinking about social and emotional wellbeing or mental health services in the local area in general, how easy do you think Aboriginal children and young people find them to access?
PROMPT: If easy, what things are in place that make it easy? Are there certain services or types of services that are particularly easy to access? Are services for infants/primary school aged kids/ adolescents/young adults equally easy to access?
PROMPT: If not easy, what makes it hard? Are there certain services or types of services that are particularly hard to access?
PROMPT: What are the things that help Aboriginal children and young people access mental health care and support?] Are these the same for infants/primary school aged kids/ adolescents/young adults?
PROMPT: Are ED services and inpatient care easy to access? If not easy, what makes access difficult? What might help improve access?
TO BEGIN
EARLY INTERVENTION
ACCESSIBILITY
WORKSHOPS AND INTERVIEWS| SAX INSTITUTE 3
3. When you/they go to a mental health or social and emotional wellbeing service, what kinds
of things do YOU think help make people feel comfortable and respected as an Aboriginal person?
Note: If the group has non-Aboriginal participants, you might want to indicate that you are aware that not everyone has lived experience of this, but we would like to hear their opinions anyway.
PROMPT: Are there things to do with who works at the service and who attends your sessions? The other clients? How the service looks physically? What the clinicians ask or say to and how they say it? What do these things mean, or tell clients, from your point of view?
PROMPT: Do services and staff usually do these things? Are there areas you think your service could improve on?
PROMPT: Are the things Aboriginal young people and families need to feel comfortable and respected as Aboriginal people different when they are accessing ED or inpatient care for mental health? Do ED and inpatient services in your area usually provide these things? If not, how could they improve?
4. As you know, children and young people with mental health challenges often need support from various services. What is your experience of how services in this area link together for Aboriginal children and young people?
PROMPT: Is it easy for clients to move between services? If yes, what helps make this easy? If no, what are the barriers?
PROMPT: Do the different clinicians and services work well together (communicate about how their clients are going, share important information)? Where this does work well, what helps? Where is does not, what are the barriers?
PROMPT: How smooth are the links between ED and inpatient services for mental health and services in the community? What is working well? What could be improved?
5. So, we have covered a lot of ground talking about specific aspects of the mental health service system for Aboriginal children and young people. Let’s now try think about how things are working overall. How well do you think the mental health service system in (X LHD) is working for Aboriginal young people?
PROMPT: Are there particular services, programs or supports that you think are working particularly well? Why? How well do you think ED and inpatient mental health services are working for Aboriginal children and young people?
PROMPT: We started by thinking about what the mental health service system might look like in a perfect world, let’s finish by getting really practical. What kinds of things do you think could be done now, without a big funding boost, to make the mental health service system in X LHD work even better for Aboriginal children and young people?
CULTURAL SAFETY – Please don’t use the term ‘cultural safety’ when facilitating
INTEGRATED SERVICES
EFFECTIVENESS
WORKSHOPS AND INTERVIEWS| SAX INSTITUTE 4
6. Is there anything we haven’t asked about that you would like to tell us about the services, programs
or supports available to Aboriginal children and young people in X LHD?
Thank you for sharing your knowledge and wisdom today.
Before you go, we would like to ask you to please fill out this short survey. You can also write any comments on this that you maybe did not have a chance to get across during discussions. Please let us know if any of the questions are not clear.
We would also like to invite you to write your email address on this piece of paper (or postal
address) if you would like to be sent a transcript of what was said in our session today. If you think anything has been recorded incorrectly, you can let us know.
Lastly, we would like to invite you to come to a workshop early in the new year where we will
discuss what we have learnt about the mental health service system in X community for Aboriginal children and young people – what’s working well and opportunities for improvement.
FINAL COMMENTS
Appendix 2: Examples of ongoing engagement, research progress updates and communication with SEARCH Study ACCHS
113
Jasper Garay USYD/SEARCH
Masters Thesis
Title: Social and Emotional Wellbeing (SEWB) service experiences of Aboriginal young people in NSW: listening to voices, respecting experiences, improving outcomes
Aim: To promote Aboriginal young people’s experiences, opinions, and suggestions as valuable evidence that should help to guide SEWB/Mental Health service reforms in NSW for better health outcomes
Overview: My thesis involves: -Defining SEWB and relating its importance to Aboriginal people’s health and wellbeing -Exploring ways and examples of why SEWB is relevant in the Aboriginal health context -Evaluating previous and current contributing factors to SEWB outcomes -Review of SEWB/Mental Health policies, review of available literature and research involving SEWB and young people in Australia -Reporting, discussion, and evaluation of the information provided by young people from our interviews at two AMS located in NSW -Recommendations and conclusion section that champions what was said by Aboriginal young people, matched with available best practices found in available research to guide recommendations for change
What young people said about five key areas of SEWB care: Talking about the five following themes allowed young people to report information on areas that would help improve SEWB care. By having a platform to voice experiences and suggestions, we’re able to align these ideas with aspects of needed improvement in the current SEWB system and services.
Access: Participating young people reported that there were not enough SEWB services in their area for Aboriginal young people. Not knowing what services exist in the local area adds to this issue. Shame of seeking help, and mainstream services not being appealing to young people remains a problem. AMS strengths included being approachable, understanding, and having a presence in the community that can be trusted for access to SEWB care. SEWB services and programs offered at and run by AMS were wanted. Better assistance and guidance to understand what is involved in SEWB care and support persons assisting with processes of help seeking were suggested as beneficial when navigating the SEWB care system, helping to decrease shame and uncertainty of accessing available options of care. Most young people felt that there needed to be greater advertisement and accessible information on what care is available in the AMS region. Better focus on person centred care is wanted, including service changes that include holistic approaches to health, not being purely Westernised clinical medical models of SEWB/mental health care.
Early Intervention: Young people reported that some good early intervention programs exist, however many more are needed. Schools were considered by young people to be the most promising places for early interventions with younger ages to occur, with further support to begin
Jasper Garay USYD/SEARCH
Masters Thesis
early interventions from much younger ages in the future. Young people felt that the services and programs that are effective were designed and led by Aboriginal people, especially those that prioritised cultural empowerment and engagement.
Service Integration: AMS however was mentioned on multiple occasions as having positive health worker support when transferring or re-entering a service. Referral processes and transitioning between services was reported to be difficult and under supported. Young people reported that this could be enhanced by having more in house SEWB options of care at AMS. Communication and information provided after seeking help was often found to be inaccurate or confusing. More effective advertising of what is available and how to access it was thought to be needed.
Cultural Safety: Aboriginal people working in services on many occasions was vital to good experiences. Experiences at mainstream organisations were thought to be culturally unsafe and challenging due to lacking overall cultural safety, cultural awareness, and clouded by negative pairings with unsuitable SEWB health workers. Young people reported that mainstream services need to be more engaged with community, and actively increase efforts to be more welcoming for Aboriginal people and be relevant to Aboriginal young people’s cultural and SEWB needs.
Effectiveness: AMS was considered by young people to be a longstanding, trustworthy, and culturally appropriate service to seek SEWB care and support. AMS was suggested to approach providing SEWB care and programs rather than referring out to mainstream options. Overall, experiences of mainstream SEWB services were reported to be poor. Many factors young people highlighted as requiring change were not bigger system level changes, but service provider and health worker changes. Currently Aboriginal young people felt they were not adequately supported for SEWB in the mainstream system and were rarely involved in helping to identify what changes could be made.
1
Jasper Garay USYD/SEARCH
Masters Thesis
Title: Social and Emotional Wellbeing (SEWB) service experiences of Aboriginal young people in NSW: listening to voices, respecting experiences, improving outcomes
Aim: To promote Aboriginal young people’s experiences, opinions, and suggestions as valuable evidence that should help to guide SEWB/Mental Health service reforms in NSW for better health outcomes
Overview: My thesis involves: -Defining SEWB and relating its importance to Aboriginal people’s health and wellbeing -Exploring ways and examples of why SEWB is relevant in the Aboriginal health context -Evaluating previous and current contributing factors to SEWB outcomes -Review of SEWB/Mental Health policies, review of available literature and research involving SEWB and young people in Australia -Reporting, discussion, and evaluation of the information provided by young people from our interviews at AMS and AMS -Recommendations and conclusion section that champions what was said by Aboriginal young people, matched with available best practices found in available research to guide recommendations for change
What young people said about five key areas of SEWB care: Talking about the five following themes allowed young people to report information on areas that would help improve SEWB care. By having a platform to voice experiences and suggestions, we’re able to align these ideas with aspects of needed improvement in the current SEWB system and services.
Access: Participating young people reported that there were not enough SEWB services in their area for Aboriginal young people. Not knowing what services exist in the local area adds to this issue. Shame of seeking help, and mainstream services not being appealing to young people remains a problem. AMS strengths were flexible arrangements for calling, arranging, and accessing SEWB care. Outreach services and youth workers were also helpful to better accessing care. Shorter waiting times, later opening times, and transport to appointments were suggestions for improvement, including expanding on the listed positives.
Better focus on person centred care is wanted, including service changes that include holistic approaches to health, not being purely Westernised clinical medical models of SEWB/mental health care.
Early Intervention: Young people reported that some good early intervention programs exist, however many more are needed. Young people shared more negative experiences of Emergency Department settings than good experiences of early interventions. Increasing screening at an earlier age was recognised as needed. Young people felt that the services and programs that are effective were designed and led by Aboriginal people, especially those that
2
Jasper Garay USYD/SEARCH
Masters Thesis
prioritised cultural empowerment and engagement. Schools were considered by young people to be the most promising places for early interventions with younger ages to occur.
Service Integration: Referral processes and transitioning between services was reported to be difficult and under supported. Communication and information provided after seeking help was often found to be inaccurate or confusing. More effective advertising of what is available and how to access it was thought to be needed.
Cultural Safety: AMS was identified as leading the way in delivering culturally safe SEWB care in x LHD. Aboriginal people working in services on many occasions was vital to good experiences. Experiences at the Emergency Department were thought to be particularly culturally unsafe and challenging to access effectively. Young people reported that mainstream services need to be more engaged with community, and actively increase efforts to be more welcoming for Aboriginal people, and to be relevant to Aboriginal young people’s cultural and SEWB needs.
Effectiveness: AMS was considered by young people to be leading successful SEWB service provision and support to accessing SEWB care. Overall, experiences of mainstream SEWB services were reported to be poor. Many factors young people highlighted as requiring change were not bigger system level changes, but service provider and health worker changes. Currently Aboriginal young people felt they were not adequately supported for SEWB in the mainstream system and were rarely involved in helping to identify what changes could be made.
Update: SEARCH Investigators’ meeting, 12th
February 2020
Community-driven approaches to mental health service system improvement for Aboriginal children and young people
Collect the evidence needed to drive mental health system improvement for Aboriginal children and young
people
Work with our AMS partners to use this information to advocate for change
Track what change occurs, why (or why not) and what
difference it makes
Identify effective ways to bring about AMSs-led mental health system change to improve the social and emotional wellbeing of
Aboriginal young people
Research aims
South West Sydney o Tharawal ACCHS o South West Sydney LHD (SWSLHD)
Wagga Wagga
o Riverina Medical and Dental Aboriginal Corporation (RivMed) o Murrumbidgee LHD (MLHD) o Murrumbidgee Primary Health Network (MPHN)
Orange
o Orange AMS: New partnership for 2020
Partners
One-on-one and focus group data have been conducted at Tharawal ACCHS and with mainstream health professionals in Campbelltown, and at RivMed ACCHS. – Tharawal (n=48)
– Rivmed (n=29)
– Survey data from 67/77 (87%)
Orange AMS
– Ethics amendment lodged
– Met with CEO (Jamie) and the Wellbeing Centre staff
Progress to date
Analysis of major themes is currently underway Preliminary analysis found: Barriers to access: lack of specialist services, long waiting periods, shame
stigma, inflexible mainstream services Cultural safety: Racism and discrimination (mainstream frontline staff), lack
of Aboriginal mental health workers Integration: Poor communication (discharge information), difficulties
navigating the system (space for a MH advocate) Early intervention: Lack of services (expensive or intermittent), need for
more programs in schools Effectiveness: Rapport/trust, flexible/patient centred (ACCHS model),
holistic
Results
How comfortable and respected do Aboriginal young people feel when accessing mental health services?
Always 4
Most of the time 3
About half the time
Hardly ever 1
Never 0
ACCHS services
Mainstream services
Emergency Dept.
Young people Carers ACCHS staff Mainstream staff
Results
2
From initial feedback, the SWS LHD has indicated they are planning to:
– Create a new role for an Aboriginal Liaison Officer with a specific focus on Campbelltown Hospital
ED
– Implement new systems for following up Aboriginal patients who haven’t completed treatment
– Strengthen the mental health inpatient linkage with Tharawal ACCHS
SWSLHD met with the PHN to discuss improving access to headspace for Aboriginal
youth and providing more outreach services based at ACCHSs
Impact
Finish collecting data at RivMed and with MLHD – Mainstream interviews, young people, caregivers
Conduct feedback sessions for ACCHSs and LHD Conduct interviews with ACCHS CEO and key external stakeholders
– Understand what changes have occurred – Understand the impact of these changes
Begin data collection at Orange AMS Prepare results for journal submissions
The next 12 months
In partnership with
With support from
Acknowledgements
Tharawal Aboriginal Medical Service Meeting 28th July 2020
Community-driven approaches to mental health service system improvement for Aboriginal children and young people
Collect the evidence needed to drive mental health system improvement for Aboriginal children and young
people
Work with our AMS partners to use this information to advocate for change
Track what change occurs, why (or why not) and what
difference it makes
Identify effective ways to bring about AMSs-led mental health system change to improve the social and emotional wellbeing of
Aboriginal young people
Research aims
South West Sydney o Tharawal ACCHS o South West Sydney LHD (SWSLHD)
Wagga Wagga
o Riverina Medical and Dental Aboriginal Corporation (RivMed) o Murrumbidgee LHD (MLHD) o Murrumbidgee Primary Health Network (MPHN)
Orange
o Orange AMS: New partnership for 2020
Partners
One-on-one data collection have been conducted at Tharawal ACCHS with 5 Aboriginal young people
Multiple meetings with SEARCH team to explore and assess what Aboriginal
young people said, aiming to utilise this data to inform changes in the SWSLHD
Final stages of thesis review underway with supervisors, aiming to submit to
University of Sydney by end of August
Progress to date
Analysis of major themes is currently underway Preliminary analysis found: Barriers to access: lack of specialist services, long waiting periods, shame
stigma, inflexible mainstream services Cultural safety: Racism and discrimination (mainstream frontline staff), lack
of Aboriginal mental health workers Integration: Poor communication (discharge information), difficulties
navigating the system (space for a MH advocate) Early intervention: Lack of services (expensive or intermittent), need for
more programs in schools Effectiveness: Rapport/trust, flexible/patient centred (ACCHS model),
holistic
Results
Access: Flexible arrangements when seeking care Aboriginal staff help people feel comfortable accessing Youth worker role important Outreach services important method of care
Tharawal AMS Results
Cultural Safety: Tailored care for Aboriginal people Understanding what Aboriginal people need in SEWB
care Comfort in seeking help due to understanding potential
SEWB problems
Tharawal AMS Results
Effectiveness: Culturally appropriate and relevant Trust in Tharawal staff and organisation’s reputation and
place in community Person centred care
Tharawal AMS Results
After hours services Increased outreach services Transport to appointments More services and programs run through Tharawal Importance of positive first contact with reception/front
desk when seeking care
Tharawal AMS: Suggestions
Finish collecting data at RivMed and with MLHD – Mainstream interviews, young people, caregivers
Conduct feedback sessions for ACCHSs and LHD Conduct interviews with ACCHS CEO and key external stakeholders
– Understand what changes have occurred – Understand the impact of these changes
Begin data collection at Orange AMS Prepare results for journal submissions
The next 12 months
111
In partnership with
With support from
Acknowledgements
111
Appendix 3: ACCHS CE/ Directors final sign off and approval for this thesis submission [provided on submission but removed from here for anonymity]
114
111
References:
Australian Bureau of Statistics. (2007). National Survey of Mental Health and Wellbeing: Summary of
results. Canberra: ABS Retrieved from https://www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/6AE6DA447F985FC2CA2574EA0 0122BD6/$File/National%20Survey%20of%20Mental%20Health%20and%20Wellbeing%20Su mmary%20of%20Results.pdf.
Australian Bureau of Statistics. (2008). Use of the Kessler Psychological Distress Scale in ABS health surveys. Canberra Retrieved from http://www.abs.gov.au/ausstats/[email protected]/mf/4817.0.55.001.
Australian Bureau of Statistics. (2017). Census of population and housing - counts of Aboriginal and Torres Strait Islander Australians, 2016. Canberra.
Australian Bureau of Statistics. (2018). Causes of Death, Australia 2017. Canberra. Australian Bureau of Statistics. (2019). Estimates and projections, Aboriginal and Torres Strait
Islander Australians, 2006 to 2031. Canberra: Australian Bureau of Statistics. Australian Government. (2016). National Aboriginal and Torres Strait Islander Peoples’ Drug
Strategy 2014 - 2019. Canberra: Australian Government. Australian Health Ministers. (1992). National Mental Health Policy. Canberra: Australian Government
Publishing Service. Australian Health Ministers. (1998). Second National Mental Health Plan. Canberra: Commonwealth
Department of Health and Family Services. Australian Health Ministers. (2003). National Mental Health Plan 2003-2008. Canberra Australian
Government. Australian Institute of Health and Welfare. (2015). National Mental Health Performance Framework
(KPIs for Australian Public Mental Health Services: PI 10 – Comparative area resources, 2015 – Health, Standard 19/11/2015). Retrieved from Published online: http://meteor.aihw.gov. au/content/index.phtml/itemId/584825:
Australian Institute of Health and Welfare. (2018). Aboriginal and Torres Strait Islander adolescent and youth health and wellbeing 2018. Canberra: Australian Institute of Health and Welfare
Australian Institute of Health and Welfare. (2018). Australia’s health 2018. Australia’s health series no. 16. Canberra: AIHW Retrieved from https://www.aihw.gov.au/getmedia/7c42913d-295f- 4bc9-9c24-4e44eff4a04a/aihw-aus-221.pdf.aspx?inline=true.
Australian Institute of Health and Welfare. (2019). Mental health services—in brief 2019. Canberra: AIHW Retrieved from https://www.aihw.gov.au/getmedia/f7395726-55e6-4e0a-9c1c- 01f3ab67c193/aihw-hse-228-in-brief.pdf.aspx?inline=true.
Australian Institute of Health and Welfare. (2020a). Australian Burden of Disease Study 2015: Interactive data on disease burden. Retrieved from https://www.aihw.gov.au/reports/burden-of-disease/abds-2015-interactive-data-disease- burden
Australian Institute of Health and Welfare. (2020b). Indigenous injury deaths: 2011–12 to 2015–16. . Retrieved from Canberra: https://www.aihw.gov.au
Ansell, N. (2016). Children, youth and development: Routledge. Askew, D. A., Brady, K., Mukandi, B., Singh, D., Sinha, T., Brough, M., & Bond, C. J. (2020). Closing the
gap between rhetoric and practice in strengths-based approaches to Indigenous public health: a qualitative study. Australian and New Zealand journal of public health, 44(2), 102- 105.
Atkinson, J. (2013). Trauma-informed services and trauma-specific care for Indigenous Australian children. 115
111
Azzopardi, P. S. (2013). Systematic reviews. The Medical Journal of Australia, 199(1), 57-63. Azzopardi, P. S., Sawyer, S. M., Carlin, J. B., Degenhardt, L., Brown, N., Brown, A. D., & Patton, G. C.
(2018). Health and wellbeing of Indigenous adolescents in Australia: a systematic synthesis of population data. The Lancet, 391(10122), 766-782.
Bainbridge, R., McCalman, J., Clifford, A., & Tsey, K. (2015). Cultural competency in the delivery of health services for Indigenous people.
Bessarab, D., & Ng'andu, B. (2010). Yarning about yarning as a legitimate method in Indigenous research. International Journal of Critical Indigenous Studies, 3(1), 37-50.
Biddle, N., & Swee, H. (2012). The relationship between wellbeing and Indigenous land, language and culture in Australia. Australian Geographer, 43(3), 215-232.
Birchwood, M., & Singh, S. P. (2013). Mental health services for young people: matching the service to the need. The British Journal of Psychiatry, 202(s54), s1-s2.
Blignault, I., Haswell, M., & Pulver, L. J. (2016). The value of partnerships: lessons from a multi-site evaluation of a national social and emotional wellbeing program for Indigenous youth. Australian and New Zealand journal of public health, 40(S1), S53-S58.
Bond, C. J., & Singh, D. (2020). More than a refresh required for closing the gap of Indigenous health inequality. The Medical Journal of Australia, 212(5), 198-199. e191.
Boulton, J. (2016). Aboriginal children, history and health: Beyond social determinants: Routledge. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in
psychology, 3(2), 77-101. Brockman, R., & Dudgeon, P. (2020). Indigenous Clinical Psychology in Australia: A Decolonising
Social–Emotional Well-Being Approach. In Beyond the Psychology Industry (pp. 83-93): Springer.
Brundtland, G. H. (2000). Mental health in the 21st century. Bulletin of the world Health Organization, 78, 411-411.
Burbidge, B. (2017). Traditional healers of Central Australia: Ngangkari [Book Review]. Australian Aboriginal Studies(1), 117.
Burgess, P. M., Pirkis, J. E., Slade, T. N., Johnston, A. K., Meadows, G. N., & Gunn, J. M. (2009). Service use for mental health problems: findings from the 2007 National Survey of Mental Health and Wellbeing. Australian and New Zealand Journal of Psychiatry, 43(7), 615-623.
Byrne, P. (2000). Stigma of mental illness and ways of diminishing it. Advances in Psychiatric treatment, 6(1), 65-72.
Calma, T., Dudgeon, P., & Bray, A. (2017). Aboriginal and Torres Strait Islander social and emotional wellbeing and mental health. Australian Psychologist, 52(4), 255-260.
Commonwealth of Australia. (2009). Fourth National Mental Health Plan: An agenda for collaborative government action in mental health 2009–2014. In: Commonwealth of Australia Canberra.
Commonwealth of Australia. (2017). The fifth national mental health and suicide prevention plan. In: Australian Government Canberra.
Commonwealth of Australia. (2018). Special Gathering Statement: Closing the Gap Refresh building pathways for future prosperity. Canberra: Commonwealth of Australia.
Corrigan, P. W. (2000). Mental health stigma as social attribution: Implications for research methods and attitude change. Clinical psychology: science and practice, 7(1), 48-67.
Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). The impact of mental illness stigma on seeking and participating in mental health care. Psychological Science in the Public Interest, 15(2), 37-70.
Corrigan, P. W., Mittal, D., Reaves, C. M., Haynes, T. F., Han, X., Morris, S., & Sullivan, G. (2014). Mental health stigma and primary health care decisions. Psychiatry research, 218(1-2), 35- 38.
Council of Australian Governments. (2006). National Action Plan on Mental Health 2006- 2011: Council of Australian Governments.
111
Council of Australian Governments. (2009a). National Indigenous reform agreement (closing the gap) Canberra: Council of Australian Governments.
Council of Australian Governments. (2009b). Protecting children is everyone’s business: National Framework for Protecting Australia’s Children 2009–2020. Canberra: FaHCSIA.
Department of Health. (2014). Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013-2023. Canberra: Department of Health.
Department of Health. (2015). Australian Government Response to Contributing Lives, Thriving Communities–Review of Mental Health Programmes and Services. In: Department of Health Canberra.
Department of Health and Ageing. (2013a). National Aboriginal and Torres Strait Islander Health Plan 2013-2023: Department of Health and Ageing.
Department of Health and Ageing. (2013b). National Aboriginal and Torres Strait Islander Suicide Prevention Strategy. Canberra: Commonwealth Government of Australia
Department of Prime Minister and Cabinet. (2017). Closing the Gap: The Next Phase Public Discussion Paper. Canberra: Government of Australia Retrieved from https://closingthegaprefresh.pmc.gov.au/sites/default/files/resources/ctg-next-phase- discussion-paper.pdf.
Department of Prime Minister and Cabinet. (2017). National Strategic Framework for Aboriginal and Torres Strait Islander Peoples' Mental Health and Social and Emotional Wellbeing. Canberra: Commonwealth of AustraliaDodson, M. (1994). Towards the exercise of indigenous rights: policy, power and self-determination. Race & class, 35(4), 65-76.
Drew, N. (2015). Social and emotional wellbeing, natural helpers, critical health literacy and translational research: connecting the dots for positive health outcomes. Australasian Psychiatry, 23(6), 620-622.
Dudgeon, P., & Bray, A. (2018). Indigenous healing practices in Australia. Women & Therapy, 41(1-2), 97-113.
Dudgeon, P., Bray, A., D'Costa, B., & Walker, R. (2017). Decolonising Psychology: Validating Social and Emotional Wellbeing. Australian Psychologist, 52(4), 316-325. doi:10.1111/ap.12294
Dudgeon, P., Bray, A., & Walker, R. (2020). Self-determination and strengths-based Aboriginal and Torres Strait Islander suicide prevention: an emerging evidence-based approach. In Alternatives to Suicide (pp. 237-256): Elsevier.
Dudgeon, P., Bray, A., Walker, R., & Darlaston-Jones, D. (2020). Aboriginal Participatory Action Research: An Indigenous methodology promoting social and emotional wellbeing and decolonisation. In The Routledge Handbook of Critical Indigenous Studies: Routledge.
Dudgeon, P., & McPhee, R. (2019). Drawing connections. Medicus, 59(9), 22. Dudgeon, P., Milroy, H., & Walker, R. (2014). Working Together: Aboriginal and Torres Strait Islander
Mental Health and Wellbeing Principles and Practice. Dugdale, P. (2020). Doing health policy in Australia: Routledge. Eckersley, R. (2007). Young people's wellbeing and the contemporary search for meaning. Journal of
Religious Education, 55(1), 41-44. Farnbach, S., Eades, A.-M., Fernando, J. K., Gwynn, J. D., Glozier, N., & Hackett, M. (2017). The
quality of Australian Indigenous primary health care research focusing on social and emotional wellbeing: a systematic review. Public health research & practice, 27(4).
Farnbach, S., Eades, A.-M., Gwynn, J., Glozier, N., & Hackett, M. (2018). The conduct of Australian Indigenous primary health care research focusing on social and emotional wellbeing: a systematic review. Public Health Research & Practice, 28(2).
Fforde, C., Bamblett, L., Lovett, R., Gorringe, S., & Fogarty, B. (2013). Discourse, deficit and identity: Aboriginality, the race paradigm and the language of representation in contemporary Australia. Media International Australia, 149(1), 162-173.
111
Fisher, M., Baum, F., MacDougall, C., Newman, L., & McDermott, D. (2015). A qualitative methodological framework to assess uptake of evidence on social determinants of health in health policy. Evidence & Policy: A Journal of Research, Debate and Practice, 11(4), 491-507.
Fogarty, W., Lovell, M., Langenberg, J., & Heron, M.-J. (2018). Deficit discourse and strengths-based approaches: changing the narrative of Aboriginal and Torres Strait Islander health and wellbeing. Deficit Discourse and Strengths-based Approaches: Changing the Narrative of Aboriginal and Torres Strait Islander Health and Wellbeing, viii.
Gary, F. A. (2005). Stigma: Barrier to mental health care among ethnic minorities. Issues in mental health nursing, 26(10), 979-999.
Geia, L. K., Hayes, B., & Usher, K. (2013). Yarning/Aboriginal storytelling: Towards an understanding of an Indigenous perspective and its implications for research practice. Contemporary nurse, 46(1), 13-17.
Grieves, V. (2009). Aboriginal spirituality: Aboriginal philosophy, the basis of Aboriginal social and emotional wellbeing (Vol. 9): Cooperative Research Centre for Aboriginal Health Darwin.
Groom, G., Hickie, I., & Davenport, T. (2003). Out of hospital, out of mind: Mental Health Council of Australia Canberra.
Gubhaju, L., Banks, E., Ward, J., D’Este, C., Ivers, R., Roseby, R., . . . Liu, B. (2019). ‘Next Generation Youth Well-being Study:’understanding the health and social well-being trajectories of Australian Aboriginal adolescents aged 10–24 years: study protocol. BMJ open, 9(3), e028734.
Halpern, D. (2015). Inside the nudge unit: How small changes can make a big difference: Random House.
Haswell, M. R., Blignault, I., Fitzpatrick, S., & Jackson Pulver, L. (2013). The social and emotional wellbeing of Indigenous youth: Reviewing and extending the evidence and examining its implications for policy and practice.
Hawthorne, M. (2018). Traditional Aboriginal healing and western medicine meet with Ngangkari project. Australian Medicine, 30(6), 9.
Hickie, I. B., Davenport, T. A., Luscombe, G. M., Groom, G. L., & McGorry, P. D. (2005). Australian mental health reform: time for real outcomes. Medical Journal of Australia, 182(8), 401-406.
Hinton, R., Kavanagh, D. J., Barclay, L., Chenhall, R., & Nagel, T. (2015). Developing a best practice pathway to support improvements in Indigenous Australians’ mental health and well-being: a qualitative study. BMJ open, 5(8), e007938.
Humphery, K. (2001). Dirty questions: Indigenous health and ‘Western research’. Australian and New Zealand journal of public health, 25(3), 197-202.
Jones, P. B. (2013). Adult mental health disorders and their age at onset. The British Journal of Psychiatry, 202(s54), s5-s10.
Kairuz, C. A., Casanelia, L. M., Bennett-Brook, K., Coombes, J., & Yadav, U. N. (2020). Impact of racism and discrimination on the physical and mental health outcomes among Aboriginal and Torres Strait Islander peoples living in Australia: a protocol for a scoping review.
Kalucy, D., Nixon, J., Parvizian, M., Fernando, P., Sherriff, S., McMellon, J., . . . Williamson, A. (2019). Exploring pathways to mental healthcare for urban Aboriginal young people: a qualitative interview study. BMJ open, 9(7), e025670.
Kelly, K., Dudgeon, P., Gee, G., & Glaskin, B. (2009). Living on the edge: Social and emotional wellbeing and risk and protective factors for serious psychological distress among Aboriginal and Torres Strait Islander people. Darwin: Cooperative Research Centre for Aboriginal Health.
Kessler, R. C., Andrews, G., Colpe, L. J., Hiripi, E., Mroczek, D. K., Normand, S.-L., . . . Zaslavsky, A. M. (2002). Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological medicine, 32(6), 959-976.
111
Kilian, A., & Williamson, A. (2018). What is known about pathways to mental health care for Australian Aboriginal young people?: a narrative review. International journal for equity in health, 17(1), 12.
Laverty, M., McDermott, D. R., & Calma, T. (2017). Embedding cultural safety in Australia’s main health care standards. The Medical Journal of Australia, 207(1), 15-16.
Lawrence, D., Hafekost, J., Johnson, S. E., Saw, S., Buckingham, W. J., Sawyer, M. G., . . . Zubrick, S. R. (2016). Key findings from the second Australian child and Adolescent Survey of Mental Health and Wellbeing. Australian & New Zealand Journal of Psychiatry, 50(9), 876-886.
Maher, P. (1999). A review of ‘traditional’Aboriginal health beliefs. Australian journal of rural health, 7(4), 229-236.
Martin, K., & Mirraboopa, B. (2003). Ways of knowing, being and doing: A theoretical framework and methods for indigenous and indigenist re-search. Journal of Australian studies, 27(76), 203-214.
McGorry, P., Bates, T., & Birchwood, M. (2013). Designing youth mental health services for the 21st century: examples from Australia, Ireland and the UK. The British Journal of Psychiatry, 202(s54), s30-s35.
McGorry, P. D. (2007). The specialist youth mental health model: strengthening the weakest link in the public mental health system. Medical Journal of Australia, 187(S7), S53-S56.
McGorry, P. D., Purcell, R., Hickie, I. B., & Jorm, A. F. (2007). Investing in youth mental health is a best buy. Medical Journal of Australia, 187(7), S5.
McNamara, B. J., Banks, E., Gubhaju, L., Williamson, A., Joshy, G., Raphael, B., & Eades, S. J. (2014). Measuring psychological distress in older Aboriginal and Torres Strait Islanders Australians: a comparison of the K-10 and K-5. Australian and New Zealand journal of public health, 38(6), 567-573.
McPhail-Bell, K., Bond, C., Brough, M., & Fredericks, B. (2016). ‘We don’t tell people what to do’: ethical practice and Indigenous health promotion. Health Promotion Journal of Australia, 26(3), 195-199.
Milroy, J., Dudgeon, P., Cox, A., Georgatos, G., & Bray, A. (2017). What the people said: Findings from the regional roundtables of the Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project. Journal of Indigenous Wellbeing, 2(2), 16-32.
Mohajer, N., Bessarab, D., & Earnest, J. (2009). There should be more help out here! A qualitative study of the needs of aboriginal adolescents in rural Australia. Rural & Remote Health, 9(2).
Murrup-Stewart, C., Searle, A. K., Jobson, L., & Adams, K. (2018). Aboriginal perceptions of social and emotional wellbeing programs: A systematic review of literature assessing social and emotional wellbeing programs for Aboriginal and Torres Strait Islander Australians perspectives. Australian Psychologist. doi:10.1111/ap.12367
National Aboriginal and Torres Strait Islander Health Council and National Mental Health Working Group. (2004). National Strategic Framework for Aboriginal and Torres Straits Islander People’s Mental Health and Social and Emotional Well Being 2004-09. Canberra: Department of Health and Ageing.
National Health and Medical Research Council. (2018a). Ethical conduct in research with Aboriginal and Torres Strait Islander Peoples and communities: Guidelines for researchers and stakeholders. Canberra: Commonwealth of Australia.
National Health and Medical Research Council. (2018b). Keeping research on track II: A companion document to Ethical conduct in research with Aboriginal and Torres Strait Islander Peoples and communities: Guidelines for researchers and stakeholders. Canberra: Commonwealth of Australia.
National Mental Health Strategy Evaluation Steering Committee. (1997). Evaluation of the National Mental Health Strategy: Final Report. Canberra: Australian Government Publishing Service.
O'Brien, A. (2005). Factors shaping Indigenous mental health: an ethnographic account of growing up Koori from a Gubba perspective. Australian Journal of Holistic Nursing, The, 12(1), 11.
Osbourne, K., Baum, F., & Brown, L. (2013). What works? A review of actions addressing the social
111
and economic determinants of Indigenous health: Australian Institute of Health and Welfare. Paradies, Y. (2017). Indigeneity: Before and Beyond the Law Indigenous Peoples and the Law. In:
ROUTLEDGE JOURNALS, TAYLOR & FRANCIS LTD 2-4 PARK SQUARE, MILTON PARK …. Paradies, Y., Bastos, J. L., & Priest, N. (2017). Prejudice, stigma, bias, discrimination, and health. Parker, R. M. (2013). Traditional healers help close the gap. The Medical Journal of Australia, 199(1),
45. Parter, C., Wilson, S., & Hartz, D. L. (2019). The Closing the Gap (CTG) Refresh: Should Aboriginal and
Torres Strait Islander culture be incorporated in the CTG framework? How? Australian and New Zealand journal of public health, 43(1), 5-7.
Party, N. A. H. S. W. (1989). A national Aboriginal health strategy: NAHS Working Party. Porche, D. J. (2017). Health Policy: Jones & Bartlett Learning. Priest, N., Baxter, J., & Hayes, L. (2012). Social and emotional outcomes of Australian children from
Indigenous and culturally and linguistically diverse backgrounds. Australian and New Zealand journal of public health, 36(2), 183-190.
Priest, N., Mackean, T., Davis, E., Briggs, L., & Waters, E. (2012). Aboriginal perspectives of child health and wellbeing in an urban setting: Developing a conceptual framework. Health Sociology Review, 21(2), 180-195.
Priest, N., Mackean, T., Davis, E., Waters, E., & Briggs, L. (2012). Strengths and challenges for Koori kids: Harder for Koori kids, Koori kids doing well–Exploring Aboriginal perspectives on social determinants of Aboriginal child health and wellbeing. Health Sociology Review, 21(2), 165- 179.
Priest, N., Thompson, L., Mackean, T., Baker, A., & Waters, E. (2017). ‘Yarning up with Koori kids’– hearing the voices of Australian urban Indigenous children about their health and well-being. Ethnicity & health, 22(6), 631-647.
Priest, N. C., Paradies, Y. C., Gunthorpe, W., Cairney, S. J., & Sayers, S. M. (2011). Racism as a determinant of social and emotional wellbeing for Aboriginal Australian youth. Medical Journal of Australia, 194(10), 546-550.
Purcell, R., Goldstone, S., Moran, J., Albiston, D., Edwards, J., Pennell, K., & McGorry, P. (2011). Toward a twenty-first century approach to youth mental health care: Some Australian initiatives. International Journal of Mental Health, 40(2), 72-87.
Purdie, N., Dudgeon, P., & Walker, R. (2010). Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice.
Rigney, D., & Hemming, S. (2014). Is ‘Closing the Gap’Enough? Ngarrindjeri ontologies, reconciliation and caring for country. Educational Philosophy and Theory, 46(5), 536-545.
SEARCH investigators. (2010). The Study of environment on Aboriginal resilience and child health (SEARCH): study protocol. BMC Public Health, 10(1), 287.
Sherriff, S. L., Miller, H., Williamson, A., Tong, A., Muthayya, S., Redman, S., Bailey, S., Eades, S., & Haynes, A. (2019). Building trust and sharing power for co-creation in Aboriginal health research: a stakeholder interview study. Evidence & Policy: A Journal of Research, Debate and Practice, 15(3), 371-392.
Sherwood, J. (2013). Colonisation–It’s bad for your health: The context of Aboriginal health. Contemporary nurse, 46(1), 28-40.
Sherwood, J., & Edwards, T. (2006). Decolonisation: A critical step for improving Aboriginal health. Contemporary nurse, 22(2), 178-190.
Singer, J., Bennett-Levy, J., & Rotumah, D. (2015). “You didn’t just consult community, you involved us”: transformation of a ‘top-down’Aboriginal mental health project into a ‘bottom- up’community-driven process. Australasian Psychiatry, 23(6), 614-619.
Skerrett, D. M., Gibson, M., Darwin, L., Lewis, S., Rallah, R., & De Leo, D. (2018). Closing the Gap in Aboriginal and Torres Strait Islander Youth Suicide: A Social–Emotional Wellbeing Service Innovation Project. Australian Psychologist, 53(1), 13-22.
111
Social Health Reference Group. (2004). Social and Emotional Well Being Framework: A National Strategic Framework for Aboriginal and Torres Strait Islander Peoples' Mental Health and Social and Emotional Well-Being: 2004-2009. In: Department of Health and Ageing Canberra.
Steel, D. (2008). NSW Population Health Survey: Review of Weighting Procedures. Sydney: Centre for Epidemiology and Research, NSW Health.
Swan, P., & Raphael, B. (1995). Ways forward: national Aboriginal and Torres Strait Islander mental health policy; national consultancy report.
Szoke, H. (2012). National anti-racism strategy. Australian Human Rights Commission. Thomas, D. P., Bainbridge, R., & Tsey, K. (2014). Changing discourses in Aboriginal and Torres Strait
Islander health research, 1914-2014. Medical Journal of Australia, 201(S1), S15-S18. Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research
(COREQ): a 32-item checklist for interviews and focus groups. International journal for quality in health care, 19(6), 349-357.
Townsend, M., Phillips, R., & Aldous, D. (2009). “If the land is healthy… it makes the people healthy”: The relationship between caring for Country and health for the Yorta Yorta Nation, Boonwurrung and Bangerang Tribes. Health & place, 15(1), 291-299.
Tucci, V., & Moukaddam, N. (2017). We are the hollow men: The worldwide epidemic of mental illness, psychiatric and behavioral emergencies, and its impact on patients and providers. Journal of emergencies, trauma, and shock, 10(1), 4.
Vicary, D., & Westerman, T. (2004). That’s just the way he is’: some implications of Aboriginal mental health beliefs. Australian e-Journal for the advancement of mental health, 3(3), 103-112.
Walker, M., Fredericks, B., Mills, K., & Anderson, D. (2014). “Yarning” as a method for community- based health research with indigenous women: the indigenous women's wellness research program. Health care for women international, 35(10), 1216-1226.
Walter, M. (2005). Using the'power of the data'within Indigenous research practice. Australian Aboriginal Studies(2), 27.
Warburton, J., & Chambers, B. (2007). Older Indigenous Australians: Their integral role in culture and community. Australasian Journal on Ageing, 26(1), 3-7.
Whiteford, H., Buckingham, B., & Manderscheid, R. (2002). Australia's national mental health
strategy. The British Journal of Psychiatry, 180(3), 210-215. Wilkie, M. (1997). Bringing them home: Report of the national inquiry into the separation of
Aboriginal and Torres Strait Islander children from their families: Human Rights and Equal Opportunity Commission.
Williamson, A. B., Raphael, B., Redman, S., Daniels, J., Eades, S. J., & Mayers, N. (2010). Emerging themes in Aboriginal child and adolescent mental health: findings from a qualitative study in Sydney, New South Wales. Medical Journal of Australia, 192(10), 603.
Wright, D., Gordon, R., Carr, D., Craig, J., Banks, E., Muthayya, S.,Wutzke, S., Eades, S., & Redman, S., on behalf of the SEARCH collaborators. (2016). The study of environment on Aboriginal resilience and child health (SEARCH): a long-term platform for closing the gap. Public Health Research and Practice. 26(3).
Young, C., Hanson, C., Craig, J. C., Clapham, K., & Williamson, A. (2017). Psychosocial factors associated with the mental health of indigenous children living in high income countries: a systematic review. International journal for equity in health, 16(1), 153.
Young, C., Tong, A., Sherriff, S., Kalucy, D., Fernando, P., Muthayya, S., & Craig, J. C. (2016). Building better research partnerships by understanding how Aboriginal health communities perceive and use data: a semistructured interview study. BMJ open, 6(4), e010792.
Ypinazar, V. A., Margolis, S. A., Haswell-Elkins, M., & Tsey, K. (2007). Indigenous Australians’ understandings regarding mental health and disorders. Australian & New Zealand Journal of Psychiatry, 41(6), 467-478.
Zubrick, S., Silburn, S. R., Lawrence, D., Mitrou, F. G., Dalby, R., Blair, E.,Griffin, J., Milroy, H., De Maio, J., Cox, A., & Li, J. (2005). The Western Australian Aboriginal Child Health Survey: The social and emotional wellbeing of Aboriginal children and young people: Curtin University of Technology and the Telethon Institute for ChildHealth Research
121