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THE POLITICAL IS THE CLINICAL

THE POLITICAL IS THE CLINICAL. Comfort zones, cultural safety and Indigenous ‘mental’ health MURU MARRI INDIGENOUS HEALTH UNIT. In Summary. MH services fail blackfellas in multiple ways Re-conceptualising MH as well-being is likely to enhance outcomes, but mandates

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THE POLITICAL IS THE CLINICAL

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  1. THE POLITICAL IS THE CLINICAL Comfort zones, cultural safety and Indigenous ‘mental’ health MURU MARRI INDIGENOUS HEALTH UNIT

  2. In Summary • MH services fail blackfellas in multiple ways • Re-conceptualising MH as well-being is likely to enhance outcomes, but mandates organisational change

  3. In Summary • International indigenous experience offers clues, but there are crucial elements unique to the Australian situation • Change involves a suite of personal and political challenges, de-‘Othering’ and culturally safe practice

  4. Indigenous Health Status • Worst of any group in Australia • Median age death (males) 51 yrs - 26 yrs < non-Indigenous • Life expectancy ↓ Maori, Aboriginal Canadian, Native American • Many conditions preventable

  5. Mental Health Status • NSW figures: self-reported ‘mental distress’ almost 2 x non-Indig. rate • Specific diagnoses: depression, anxiety, bi- polar disorder, complex PTSD, borderline personality disorder, A&OD misuse, cannabis/amphetamine psychosis, but …

  6. Focus on ‘Mental’ Health / Illness • History of incorrect diagnosis • History of medical complicity in eugenics movement, ‘locked’ hospitals, child removal and separatist political schemes • Negative, ‘deficit’ approach – ignores social, historical and cultural aspects, including resilience

  7. Then

  8. Now

  9. I’m not ‘mental’ Narrow approach: no longer acceptable • Stigma • Lack of fit with Koori understandings • Ignores on-going loss and contemporary consequences of trans-generational trauma • Ignores the crucial contribution of exogenous, early psychic trauma

  10. I’m not ‘mental’ • Psychobiology / Body memory of trauma – Bessel van der Kolk • Psychoneurobiology / Developing brain & trauma – Bruce Perry, Alan Schore • Intergenerational Trauma – Yael Danieli • Critical Psychology – Erika Apfelbaum • Critiques of Bio-Psychiatry – Peter Breggin

  11. Indigenous Perspective • Blackfellas say fundamental connection between colonization and ‘mental distress’ • Holistic approach: mental health inseparable from overall health • Preferred term is social, spiritual and emotional well-being

  12. Positive Approaches Jettison ‘Deficit’ Model, i.e. that: • Inherited factors explain most Indigenous Australian mental distress • The rest is sheer bloody-mindedness: ‘blacks behaving badly’

  13. Positive Approaches • Attend to the social determinants of health: the role of history, politics, geography, culture and socio-economic status • Incorporate recognition of culture and the contexts of people’s lives into treatment/prevention

  14. Towards an integrated model

  15. Indigenous / CALDB well-being • Common aspects to working across Indigenous and CALDB populations? Yes • Same thing? No: unique aspects of Aboriginal and Torres Strait Islander situation

  16. ‘First Nations’ Status • Aboriginal and Torres Strait Islander Australians occupy a unique position as the original inhabitants of Australia • Sovereignty has never been ceded or attenuated by treaty

  17. Indigenous Health Status Effects of 200 years of colonization on health • Dispossession – land, language, culture, economic base → grief and loss • ‘Stolen Generations’ • Trans-Generational Trauma • Multi-Generational Chronic Stress • Racism, discrimination and ‘virtual’ apartheid

  18. Colonization to healing • Clue from NZ MH competency framework ~ Specific reference to healing for Maori • Similar calls in Australia, but not mandatory - little recognition of: ~ Effects of colonization on health ~ Relationship of ATSI to land / spirituality ~ Sovereignty issue

  19. Big picture: treaty and health

  20. Big picture: culture and health • Connection to culture, language, land ‘protective’ of well-being (Aust./NZ, Jane McKendrick) • Notion of ‘Cultural Resilience’ (US, Iris HeavyRunner and Kathy Marshall)

  21. Big picture: culture and health

  22. Big picture: Cultural Presence Cultural Safety / Cultural Security affected by relative presence or relative absence of Indigenous culture in the life of the nation

  23. Big picture: Minoritisation • Bruce Perry: psychologically fraught to leave the living culture of the reservation / whanau / Aboriginal community to become a ‘minority’ individual in a western cultural framework • Minoritisation = a reduction in regard

  24. Big picture: Minoritisation • Does such ‘minoritisation’ multiply the effects of marginalisation? • When you’re already culturally absent / beyond the pale, does that make it even easier to become diminished or infantilised as a person?

  25. Clinical picture: better praxis Ngara “Listen, hear, think … (Eora, the Sydney language) to listen is simultaneously to reflect and become self-aware.”* * Paul Carter

  26. Clinical picture: better praxis Resonance with Cultural Safety Precept of health professional self- reflection / examination of own cultural system

  27. De-Othering Indigenous Australia • Acceptance of alterity, small ‘o’ otherness • Cultural Imbrication / Cultural Interaction • Up-close-and-personal involvement • Everyday enmeshment, rather than policy fiat

  28. Accepting small ‘o’ otherness

  29. Extending our praxis To improve Indigenous social, spiritual and emotional well-being it’s time to: • Move beyond DSM IV • Move beyond diagnose / treat • Go further than the client / professional dyad

  30. Extending the model

  31. The political is the clinical • Aboriginal and Torres Strait Islander emotional well-being a complex endeavour • Need for positive approaches, a taking account of social determinants and grappling with unfamiliar imperatives: cultural competence / cultural safety / cultural imbrication

  32. But … all this implies • Personal challengeto existing comfort zone • Professional challenge # To models of professional distance and non- disclosure # Mandates organisational change

  33. But … all this implies • Political Challenge #Implications for training: systems/funding #Implications for competency standards # Implied need for increased practitioner advocacy

  34. ‘Not For Service’ Rpt. Calls For • Funding: increase MH to 12 per cent of total health care funding • Policy: monitoring extent of MH problems PLUS A&OD integration with the National MH Strategy • Leadership and governance: federal Minister PLUS true collaboration between all stakeholders

  35. ‘Not For Service’ Rpt. Calls For • Legal and Human Rights: nationally consistent guidelines on the provision of MH care • Workforce: urgently address the declining morale and chronic skills shortages in the MH workforce • Accountability: annual reporting mechanism on key indicators, including 10-year targets

  36. The political is the clinical • Re-emerging role for public intellectual in conservative times • Australian Govt. denial of contemporary consequences of past practices leads to inequitable, ineffective policy • Time to re-conceive role of health professional as public professional

  37. The political is the clinical • Governmental and organizational denial can be as unshakeable as alcoholic denial • Confrontation with evidence-base for fresh approaches to Indigenous well-being a necessary, but not sufficient condition

  38. The political is the clinical • Clinical duty of care mandates a ‘political’ set of activities to circumvent denial • Could be pursued through changes to the parameters, language and tone of the debate • Requires practitioner involvement in creation of a parallel discourse

  39. The political is the clinical Time for Boldness • Insist government policy founded-on contemporary effects of loss and TGT • Insist initiatives be funded according to need, are sustainable • Insist anything else violates professional duty of care

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