Cultural intelligence

Since the colonisation of Australia over 250 years ago, the original inhabitants, Aboriginal and Torres Strait Islander people, have suffered immensely. From the initial years of countless lives lost through their interactions and one-sided battles with white settlers and British armies, to the no less deleterious oppressive racism and legislation that forced the separation of families, the policies of the Australian government and attitudes of the wider community created transgenerational trauma that still reverberates deeply to the present day (Menzies, 2019).

So many of the problems facing Indigenous Australians can be traced to this not too distant past, and our attempts to ameliorate the issues have ignored the social, political and historical contexts, and instead have tried foisting western notions of health and wellbeing onto a people steeped in thousands of years of cultural norms and practices (Dudgeon et al, 2014).

A thorough examination of the literature elucidates how the social, emotional and mental wellbeing of Indigenous Australians is complex and multifaceted, entwined into the health of their family, community and culture. The practical clinical implications are discussed, and an overview presented of how using an Indigenous world view can improve the treatment options available to those concerned with the wellbeing of Aboriginal and Torres Strait Islander people and their communities.

Mental health in the Indigenous context

The prevailing western paradigm of health is primarily individualistic, an island of functioning biological systems, independent of their personal, familial and societal circumstances (Carrie, 2015).

This is in stark contrast to Aboriginal and Torres Strait Islander people, for whom the concept of health and wellbeing sit in the centre of a complex web of interactions with kin, spiritual ancestors, country, community and a whole host of other important factors (Grieves, 2009).

Using a framework where health is a multidimensional and interconnected concept is even more important when addressing the mental health issues facing Indigenous people. Even the words 'mental health' fail to appreciate the complexities at play, and the term social and emotional wellbeing (SEWB) is preferred as it encompasses a more holistic perspective of how Indigenous people view their own wellbeing and mental health (Social health Reference Group, 2004).

As a concept, SEWB was developed from the Ways Forward 1995 report with nine guiding principles (see appendix 1) underlying it, such as 'recognition of the centrality of kinship,' and 'the impact of history in trauma and loss (Swan, Raphael, 1995).

And while delving into each of the nine principles is unfortunately beyond the scope of this article, each principle emphasises this central concept, that the mental health of an individual Indigenous Australian cannot be viewed as a locus separate from their environment, but it is the totality of their SEWB, woven into the fabric of their community, health of their family and strength of their connection to culture that matters most.

Therefore, to see the world through Indigenous eyes and to make inroads into improving the health outcomes of Indigenous people, means we must stop viewing the issue through a western lens;  instead we must transition to a more holistic, culturally-sensitive approach that is reflected in all levels of the healthcare system, starting from identification and treatment options to follow-up care, and even the terminology we use to define the problems at hand (Wilczynski et al, 2007).

The importance of this perspective change is stressed if we focus our attention on the current SEWB outcomes of Indigenous Australians. The Australian Bureau of Statistics show Aboriginal people report experiencing psychological distress at two-and-a-half times the rate of other people, and are hospitalised for mental health and behavioural disorders at around 1.7 times the rate of non-Aboriginal people; (Australian Cultural intelligence: Bureau of Statistics [ABS] 2019).

The gravity of these statistics, and other similar ones, urgently demands moving away from an individualistic approach to progressing the mental health of Indigenous people, and rapidly transitioning to programs and interventions that utilise the many family, community and culture based factors that underpin the SEWB of Aboriginal and Torres Islander people.

A difference in perspective

Another way that seeing social and emotional wellbeing through Indigenous eyes can improve those outcomes is by realising that the presentations and symptoms of mental health issues can vary greatly compared to other Australians.

While the DSM 5 is an invaluable tool for identifying mental health conditions, it often fails to appreciate cultural differences in symptomatology that are incompatible within a western schema of diagnosis, which can have flow-on effects into treatment options and prognosis (Langa, Gone, 2009).

Brown et al's (2012) work with Aboriginal males in central Australia showed the primary words these men identified as best reflecting their symptoms were excessive worry, sadness and anger, which culminated in a weakening of their spirit, known as Kurunpa. The men articulated how this Kuranpa, which is the life force which runs through them, was weakened by the repetitive insults that historical institutionalisation, community dysfunction and substance abuse levied on them, and manifested in 'depressive symptoms'.

Indigenous mental health symptoms may also differ from western psychiatric norms through idiosyncratic cultural presentations that have their roots in the strong and often permanent connection Aboriginal and Torres Strait Islander people have with spiritual ancestors, traditional land and community settings.

'Longing for country' is a specific culture-bound condition that incorporates the sadness and negative emotions an Indigenous person feels for their ancestral lands from which they have been removed, or if they remain there physically, the spiritual and psychological severance that a lack of autonomy and ownership creates (Westerman, 2004).

While these symptoms would mimic other mood disorders found in the DSM5 or other diagnostic manuals, they fail to fully appreciate the underlying cultural factors that need to be addressed to help the person heal and move forward. This blindness to cultural differences in mental health presentations gets to the heart of why seeing the world through Indigenous eyes is imperative to making headway towards improving the health – particularly the social and emotional wellbeing – outcomes of this nation's most vulnerable people.

Community programmes and evidence

As discussed, Indigenous mental health sits in a wide context composed of most notably, family, community and country, and the ways in which common disorders such as depression differ in their presentation from accepted western norms.

It is vital however that these understandings are translated into expanding the treatment options available and improving the efficacy of existing interventions. Dudgeon et al's (2014) work outlines that if Indigenous mental health strategies are to be effective, they must reflect the nine guiding principles set out in the Ways Forward 1995 report.

In practice, this means they must be community-focused, acknowledge grief and transgenerational trauma, be culturally-responsive and must empower people to make changes in their own lives and that of their community. Their work also showed the opposite to be true.

Programmes that fail to acknowledge cultural context and Indigenous lifestyles were ineffective, and adaptation of existing interventions, while well meaning, failed to deliver the same benefits as those developed in conjunction with Aboriginal Community Controlled Health Services or similar grass roots organisations.

An initiative that exemplified this holistic approach is the Family Wellbeing (FWB) programme, which was implemented in multiple Aboriginal and Torres Strait Islander communities in Queensland and the Northern Territory. The FWB was a loosely-structured, group-sharing programme where people came together to explore personal grief, and share stories in a supportive place surrounded by members of their community and respected elders.

The programmes consisted of five separate, thirty-hour stages where varying aspects of both personal and social wellbeing were discussed, and strategies to overcomes these problems such as building healthy and strong relationships, self-reflection and learning how to provide support and counselling for friends and family, were taught.

Analysis (Haswell et al. 2010; Nguyen & Cairney 2013; Tsey & Every 2000) showed people who participated in the programme had better emotional stability, self-esteem and respect, were able to identify issues in their life and come up with practical solutions and had a greater connection with their culture and community.

It is interesting to note that the words 'mental health,' were rarely mentioned in the papers that investigated the FWB programme, but their conclusions were definitive, that by creating a culturally-sensitive and supportive environment for people to come forward and discuss, not only their own issues but those of the community, the mental wellbeing of individuals improved as well.

Changing perceptions

Seeing the world through Indigenous eyes means understanding the social, emotional and mental wellbeing of Aboriginal and Torres Strait Islander people is contingent upon, not only a person's individual circumstances, but balances in a network of intricate connections to family, community, culture and land.

Whether it be harnessing this knowledge by understanding that Indigenous patients may use different terminology to describe symptoms of common mental health conditions, to utilising group-based, culturally-sensitive programs to address the wellbeing of community members, a shift to an Indigenous perspective of approaching mental wellbeing is sorely needed.

If this change in perception is able to percolate all the way down from governments and NGO's to individual mental health professionals, improvements will be made to the health – especially mental health – outcomes of this nation's first people.

About the author

Lloyd Clode-Robert is a medical student at James Cook University, Australia.