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Seeking a way forward

There is an urgent need to reduce the burden of mental illness in Australia’s indigenous communities, reports Annie May.

Mental disorders are the second leading cause of disease burden among Australia’s indigenous people after cardiovascular disease. Yet indigenous people do not access mental health services in proportion to their need.

This is according to new research looking at the barriers and facilitators for indigenous people seeking mental health services in Australia.

While people in the general population experience barriers in seeking treatment, there are many more barriers for indigenous people, particularly at the state of actually contacting a mental health service, says lead author Anton Isaacs, from Monash University Department of Rural and Indigenous Health.

“Mainstream mental health services are often the only services available to Aboriginal and Torres Strait Islander people. However, Aboriginal and Torres Strait Islander people find it difficult and sometimes distressing to access these services,” says Isaacs.

Improving health outcomes is an ongoing issue in Australia, highlighted again by a United Nations report released earlier this year finding that Australia’s Aborigines have the worst life expectancy rates of any indigenous population in the world.

Figures also show that the death rate associated with mental disorders among Aboriginal and Torres Strait Islander males is over three times the rate for other Australian males.

Indigenous people cite a combination of factors that are responsible for their poor mental health, which include lack of employment, family violence, past government practices of removal from family, substance abuse, and poverty.

Aboriginal people have a holistic view of health, and their concepts of mental health differ from that of the mainstream population.

Mental health is considered to be an interaction between the individual, the community, and the environment, involving spiritual, social, cultural, physical, and mental well-being and issues related to land and way of life, says the study published in the International Journal of Mental Health and Nursing.

This means there are many different perceptions of mental illness among them.

The study uses as an example that in some parts of Australia, mental illness can be perceived as payback for past transgressions or even being “married the wrong way”.

Also, in some communities high prevalence disorders, like depression, are not seen as treatable conditions by Aboriginal people. Instead, they describe depression-like symptoms as a characteristic of the individual and “that’s just the way he is”.

Research suggests that even when individuals recognise that there is a problem, they may not attribute it to mental illness. Despite this, Aboriginal and Torres Strait Islander people’s involuntary hospitalisation rate is significantly increased compared to the wider community, figures show.

“Once an individual recognises that a problem exists, the next step is to decide whether seeking professional mental help could solve the problem. This process is not automatic,” says Isaacs.

“Mental illness among Aboriginal people is first managed by the family, and if this fails, the extended family is involved and later the community elders, if needed. If the situation turns out to be very difficult, the patient might be referred to the family’s traditional healer through a third person.

In most cases, the study found people with severe forms of illness who have exhausted the resources of the family and community and who have high levels of distress reach mainstream services.

However, those with less severe mental health problems didn’t receive any kind of professional help.

The decision that professional help is necessary is usually influenced by informal support networks, such as family and friends. This support network can promote or hinder access to professional mental health services, says Isaacs. If the support group feels that the problem is just due to life stresses, it becomes difficult for individuals to seek professional help.

Poverty is another barrier to seeking treatment, with individuals focused on simply meeting their basic needs of food and housing.

Other factors that can hinder making the decision to seek treatment include the stigma associated with mental illness – the shame factor.

This is the case across the general population but is more prevelant in indigenous communities.

Being culturally sensitive can lessen this stigma.

Using culturally appropriate names for services has been reported to improve acceptance by indigenous people, says the study.

Deciding to seek treatment is distinct from actually contacting the service. In the general population, Isaacs says once individuals decide that treatment is necessary, the next stages happens rather quickly; for indigenous people, the barriers at this stage are multiple.

A lack of trust in mainstream services and previous experiences of racism and discrimination is an issue.

“Indigenous staff and Aboriginal health workers who are active in their communities and are employed in mainstream mental health services help to remove the misconceptions associated with those services and can provide a key role in boosting the confidence of clients within the service, as well as acting as cultural advisors to non-indigenous service providers,” says Isaacs.

However, employing indigenous staff in mental health services can have disadvantages. Many communities are small and close knit and people might find it difficult to use a service when they are related, or live next door, to the staff.

The involvement of community elders and traditional practitioners in service provision has also been found to be valuable.

Several barriers are associated with differences in culture and a lack of understanding.

For instance, indigenous people are not comfortable talking to individuals of the opposite sex about their illness. Where possible, patients should be treated by the same sex.

Cross-cultural training of service providers would help break down barriers, however, it needs to be meaningful and not just tokenistic.

Isaacs says the community that is being served needs to be involved to ensure that appropriate protocols are used.

Although there are many factors that inhibit utilisation of mental health services by indigenous people, more research is needed to identify the highest priority in terms of planning interventions, says Isaacs.

“Although government policies have gone some way towards addressing the unique mental health a needs of indigenous people, implementation of these initiatives has been slow, resulting in little improvement in the mental health and well-being of indigenous people over the last decade.”

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