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Indigenous Mental


Dedicated to Dr Mark Sheldon

MBBS (Syd. Univ) FRANZCP (1997)

19 July, 1964 - 28 May, 1998

Aboriginal or Torres Strait Islander person

someone who is of Aboriginal and/or Torres Strait

islander descent
who identifies as being Aboriginal and/or Torres
Strait islander
who is accepted as Aboriginal or Torres Strait
islander by their indigenous community

Culture Dispossession & Other difficulties

The British colonization of Australia in 1788 leading to
destruction of optimum physical and mental good
introduction of new diseases
Stolen Generation (1930 1960)
Problems integrating with modern westernised society
multigenerational social, financial, psychological and
cultural effects
almost everyone affected

Alcohol and drugs (chemical dependencies, comorbidities

or dual diagnoses, self medicating without medical
supervision, solvent sniffing)
Diet and nutrition
Language and culture
Racism and discrimination
Domestic violence
Poor Father-and-son relationships

Crowded households
Poor access to health services for remote
for urbanised Indigenous Australians, cultural
pressures which prevent access to health services
Cultural differences resulting in poor communication
between Indigenous Australians and health workers
Internal conflicts between families especially where
one family gains prominence in the local council
Fair indigenous patients issues

The Gap
Infant mortality rates was almost double (6.2 per
Death rates 5 or more times higher
4 times more likely to be hospitalised for chronic
3 times more likely to suffer from diabetes
Death rate for diabetes 7 times higher
maternal death rate 3 times

4.5 times admission for Psychosis

2.7 times admission for Schizophrenia
1.2 times admission for mood & neurotic disorders
50% of total Australian suicide (5% in 1991), despite
making up only 3% of the total Australian population
youth suicide 80% of total (10% in 1991)
The hospitalisation rate for intentional self-harm
increased by almost 50 per cent 2005 to 2013
3 times more likely to experience high/very high
levels of psychological distress

40% of Indigenous youth aged 1317 will

experience some form of mental illness
8 times more likely to experience child
One third less chance of completing School
unemployment rate around five times
19.3% living below the poverty line vs 12.4%
23% live in overcrowded households (60% in
Remote regions)
median income $465 vs $869

children on care and protection orders was 49.3

per 1000 children vs 5.7 per 1000
hospitalisation rates for family violence-related
assault 30 times
over a quarter of the adult prison population
imprisoned at 13 times the rate
detention rate 24 times

How Westernised or how traditional
culturally safe practice is simply defined as effective clinical
practice for a person from another culture
unrecognised miscommunication is pervasive
English is usually not the first language
use of Aboriginal mental health workers & translational services
differing belief systems regarding illness
perceived inefficiency of health systems
disempowerment of Aboriginal patients
poor compliance issues

specific cultural context of presentation

culturally appropriate symptoms
potential stressors
identified carers and problems affecting those
familiarity of an interview setting
involvement of family
Indigenous concept of time

structured assessment involving measurement and
rating is likely to be unfamiliar and threatening
History of Screening Tools
Standard reaction times
No need to complete a task quickly
May not see the importance of being able to separate
past and present on a longitudinal calendar axis
Measurement scales including numerical or other
categories of gradation (e.g. mild, moderate, severe)
may have very limited applicability

Normal schema fails

Starting with open ended questions puts too much
Aboriginal language does not have multiple choice
'too much worry questions'
simply say 'yes' to the questions to please the
Too many close ended questions - 'yes bias'

Talk slowly
Wait for considerable time for the answer
Commence not with questions but with non
threatening statements
Involve AHW as much as possible
Story telling Fictitious third Person
Seek permission to precede with the sensitive topics
(Bereavement/Sorry Business, the breaking of
taboos, ceremonial business, sexuality and fertility,
and domestic habits)

Using images, visual scales or colours

Gradation of symptom severity using a spectrum of
different shades of the same colour
Make a lengthy and unhurried description of your role
Ask the patient where they would like to sit to talk
Amount of personal space required is more
sit side-by-side
Loose handshake, with arm fully outstretched
Only fleeting eye contact
Greet the elderly first

Black fella English

Fella - man
Mob - a group of people or organization, for example, 'I
am from mental health mob
Rubbish one - a useless item, for example, 'Is this
medication a rubbish one?'
Long time - months, years
Stopping - staying, for example, 'You been stopping here
long time?'
walking round - agitation
running wild impulsivity

Grog - alcohol
Ganja, mardi - marijuana
Spirit weak - depressed mood
spirit strong - euthymic, sense of well being
tucker - food
shame job - something that would bring shame to the
talking rubbish - thought disorder or floridly delusional
thinking backwards - ? subjective description of
though disorder

inappropriate English would be: 'I am a psychiatry

registrar from the remote mental health team and
you have been referred by the DMO who wanted
me to interview you about how you are coping
with your family problems'

paraphrased to: 'I am the doctor from mental

health mob. I am stopping here for two days in the
community. The clinic doctor is worried for you, he
thinks your spirit is weak. Maybe we can have a
talk about your worries'


Strong souls assessment tool
Here and now Aboriginal assessment screening tool
Kimberley Indigenous Cognitive Assessment
Menzies School of Research Tools
Indigenous Risk Impact Screen and Brief Intervention
The Westerman Aboriginal Symptom Checklist
Westerman Cultural Competence Questionnaire
Patient Health Questionnaire (PHQ-9)

Strong souls assessment tool

A 25-item, four-factor tool for assessing social and
emotional wellbeing in Indigenous adolescents
four factors relate to anxiety, resilience,
depression and suicide risk
Menzies School of Research
Demonstrated validity, reliability and cultural
Freely available

Here and now Aboriginal assessment screening

tool (HANAA)
UWA School of Psychiatry and Clinical Neurosciences ,
Culture and Mental Health unit in close consultation
with Aboriginal people
Successful trials in the Kimberley, Broome and Perth
10 years to develop
Screening tool for SEWB, semi-structured 20 minute
yarning principle To tell their own story
Here and now mental health problems
10 domains, no problem, a small problem or a big

Kimberley Indigenous Cognitive Assessment

Only validated dementia assessment tool
45 years and above
Kimberley and Northern Territory
Cognitive, informant and functional sections
NARI, UWA, KAMSC, KACS, KIS, psychologists,
linguists, Indigenous people
Translated and back translated into Walmajarri

Tools required:
Comb, Pannikin / cup, Box of matches, Plastic
bottle with top , Watch/ timer for verbal fluency
33/39 and below indicates possible dementia
Medical History, smoking & alcohol, cognitive,
depression, family report & history, behaviour, ADL
& KICA Carer (3/16 or above)
KICA Regional/ Urban, KICA Screen
Alternate pictures (dog, horse)

Menzies School of Research Tools

Leading medical research institute dedicated to
improving the health and wellbeing of Indigenous
Australians since 1985
150+ research projects and programs
60+ remote community partnerships across
centraland northern Australia
20+ countries acrossthe Asia-Pacific
Mental health, nutrition, substance abuse, child
health, chronic diseases (cancer, kidney disease
and heart disease)

Aboriginal and Islander Mental health initiative

Assessment tools
Care Plans
Fact sheets
Flip charts

Indigenous Risk Impact Screen and Brief

13-item screening instrument for alcohol and drug
and mental health risk
Use of a brief intervention based on Prochaska and
DiClemente's Stages of Change Model
Queensland Health
IRIS Program - Australian Department of Health
and Ageing

The Westerman Aboriginal Symptom

Checklist Adults (WASC-A) & YOUTH (WASCY)
1999 - 2003 Curtin Uni
Screening tool
53 items, 6 subscales depression, suicidal
behaviours, D & A, impulsivity, anxiety, cultural
resilience, or moderators
15 minutes25 minutes
Indigenous Psychological Services (IPS)

Patient Health Questionnaire (PHQ-9)

Depression screening tool for IHD patients

Sadness and Heart Disease' project 2005 - 2006
Danila Dilba Health Service & Menzies School
9 items

E-learning modules
Indigenous EPAs in the RANZCP 2012 Fellowship
Nicheportal website

The Aboriginal Concept of Time and its Mental Health
Implications. Australas Psychiatry October 2003 11: S40-S44
Strong Souls: Development and Validation of a Culturally
Appropriate Tool for Assessment of Social and Emotional WellBeing in Indigenous Youth. Aust N Z J Psychiatry January 2010
44: 40-48

Australias Aboriginal Population and Mental Health (J Nerv Ment Dis
2010;198: 37)
Anxiety prevention in indigenous youth (Journal of Student Wellbeing
1(2):pp. 34-37)
Strong Souls: Development and Validation of a Culturally Appropriate
Tool for Assessment of Social and Emotional Well-Being in Indigenous
Youth (Aust N Z J Psychiatry January 2010 44: 40-48)
Here and Now Aboriginal Assessment: background, development and
preliminary evaluation of a culturally appropriate screening tool
(Australas Psychiatry June 2015 23: 287-292)
Kimberley Indigenous Cognitive Assessment tool (KICA):
development of a cognitive assessment tool for older indigenous
Australians (Int Psychogeriatr 2006;18:269-280)
Indigenous Cognitive Assessment Modification and Validation of the
KICA in Victoria. Phase 1. Final Report February 2013

AIMH@Menzies School of Research
The development and validation of the Indigenous Risk Impact
Screen (IRIS): a 13-item screening instrument for alcohol and drug
and mental health risk (Drug Alcohol Rev. 2007 Mar;26(2):109-17)
The development of the Westerman Aboriginal Symptom Checklist
for Youth. Abstract of Doctor of Philosophy Thesis (Westerman, T.G
We need transformative change in Aboriginal health
(Med J Aust 2016; 205 (1): 17-18.)