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Counselling interventions and indigenous mental health |
While it is widely recognised that disproportionate numbers of indigenous Australians spend time in the prison system, it is less well publicised that the prevalence of mental disorders is between 35% and 54% amongst the indigenous population.
In Queensland indigenous people are more than twice as likely as other Queenslanders to be admitted to inpatient psychiatric units. Indigenous people are also reluctant to present to community mental health services because of fear of being admitted to hospital or confined in unfamiliar surroundings. In a study conducted by Flinders University in it was estimated that 25% of Aboriginal adults in one community in South Australia had attempted suicide at some time in their lives.
Severe social dislocation and alienation from mainstream society, as well as endemic poverty and unemployment, contribute to these high rates of mental disorders.
When indigenous people do present to GPs and other health services the importance of using culturally appropriate assessment approaches needs to be emphasised, not only from a professional and ethical viewpoint, but to ensure that appropriate services are made accessible and used effectively. Some practical interviewing tips for non indigenous health professionals include the following:
Before the interview
- Allow extra time if possible.
- Empathise and reassure if suspicion or resentment is expressed due to cultural differences between you and the client.
- Check your language – do not use jargon.
- Be aware that anxiety about the interview may affect the behaviour shown.
- Identify relationships between the client and others present and be aware of their significance.
- Use short sentences, and avoid closed questions.
- Reflect on your own goals. Are they to:-
a. Defuse a crisis?
b. Provide short term solutions?
- Understand the underlying causes?
- Engage in ongoing counselling /therapy?
Cultural issues
- Do not refer to a dead person by name.
- Do not refer to certain close relatives by name (A Torres Strait islander male may not refer to his brother-in-law by name).
- Do not criticise an Elder.
- Be aware of confiding certain personal information to a member of the opposite sex: men’s and women’s business are usually kept separate.
- Do not criticise members of the extended family.
- Anxiety can be generated by interviewing someone in a confined space.
- Spiritual experiences are not necessarily hallucinations or delusions.
Interview process
Stage 1: initial contact
- Introductions.
- Acknowledge distress (if obvious).
- Establish rapport (observe non verbal cues).
- Establish reasons for referral.
- Gain permission from client (and others in attendance) for interview.
- With empathy, explain purpose of questions, timeframe, and potential outcomes.
- Allow for reflection, periods of silence and any questions.
- Observe cultural norms (eg: eye contact, seating arrangements).
- Check with client on preferences for interview with/without support from significant others.
- Allow for reflection. Check permission to interview.
Stage 2:
(Allow sufficient time for responses to questions)
- What are the presenting problems?
- Observe appearance.
- Biological factors.
- Be aware of possible somatisation symptoms.
- Check relationships – to family, country; sense of belonging /or alienation.
- Cognitive factors: belief systems; evidence of thought disorder, orientation, attention, memory, sense of reality, level of trust. Client’s perception and insight; perceptions of wellbeing, life satisfaction, happiness.
- Spiritual awareness and the significance of spiritual issues.
- General emotional state/mood, emotional stability; level of hostility.
- Fear of - people, places, treatment, hospitalisation, medical and mental health services, spiritual phenomena, stigma associated with mental illness; alienation.
- General impressions of behaviour, mannerisms, speech, movement, actions.
- Coping mechanisms.
Stage 3: interview assessment and summary
- Assess number, duration and intensity of symptoms.
- Which factors are predisposing, precipitating, perpetuating, and protecting.
- Discuss observation and assessment with client and /or significant others.
- Acknowledge client’s cooperation and courage.
- Negotiate intervention /management options.
Potential intervention issues
- Which combination of biological, psychological, social or community options will achieve the best outcomes?
- The use of spiritual and other healing methods.
- Medication issues – compliance, slow metabolism.
- Use of traditional herbs and alternative treatment methods.
- Diagnostic bias and clinical judgements.
- Consent to give information.
- Gender issues.
- Aboriginal cultural law.
- Transference issues.
- Comorbidity issues.
- Family and community support.
- Public health sector resources.
In assessing the mental state of an indigenous person it is also important to be aware that hallucinations may be seen as spiritual rather than psychotic phenomena. Expressions of anger directed at you particularly at times of family bereavement may reflect past experiences of hardship in a white culture rather than the current situation.
While as yet there are no nationally agreed guidelines on the assessment and management of indigenous mental health issues, the increasing emphasis on GPs becoming involved in counselling, case conferencing and care planning highlights the need to develop effective and pragmatic case management systems.
Tim Armstrong is the mental health project officer for the NRDGP.
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