Abstract
Keywords
With the new millennium came much reflection in which Indigenous affairs gave pause for various degrees of self-congratulation, self-recrimination, criticism and praise. On the part of some commentators it has resulted in reassessment and repositioning in relation to earlier ‘wisdom’ [1, 2]. This paper, by a psychiatrist and public health physician who has worked for 15 years in Indigenous health, mainly in the Kimberley and Far North Queensland, is similarly motivated. Over this period I have shifted from a conventional clinical framework, to a broader population health approach that has come to be known as ‘emotional and social wellbeing’ and, latterly, back to consideration of equity in access to appropriate clinical services. I argue that as important as broad, holistic constructions are in the wider arena of Indigenous affairs, psychiatric practitioners must first be attentive to clinical priorities.
Is Indigenous mental health itself a priority? As appalling as the continuing levels of ill health and premature mortality are in Indigenous communities, there are inevitably pressing competing demands on the ground. Regardless of the emphasis in the wider society, mental health is uncommonly an area of major activity at a community level. This is despite problems such as high levels of alcohol abuse and its consequences which include suicide, violence, and the abuse of women and children. We do not need to reference academic papers to make these points; they are cruelly obvious to anyone attuned to the media.
It might be argued that these are the consequences of histories of injustice and disadvantage, rather than mental health problems, and that to diagnose certain mental health problems in such settings is to commit what Arthur Kleinman [3] called a ‘category fallacy’, which is ultimately disempowering. This position is articulated by Colin Tatz [4] in a critique of psychiatric labelling and hegemony in suicide prevention. However, while acknowledging history, I contend that it is by denying immediate personal psychological states and needs that traumatized individuals are retraumatized and disempowered, a point recognized by Pearson [1]: In acknowledging the need for trauma to be specifically addressed, I would however, urge a distinction to be drawn between that trauma which is personal and immediate and may incapacitate individuals or families, and that trauma which is inherited and more remote – which renders people susceptible to problems, but does not leave them incapacitated. Prevailing discussions of trauma in Aboriginal society unhelpfully conflate these two kinds of trauma. Personal trauma needs to be recognized and attended to. [p.35]
In what follows I will touch on a number of issues which relate to psychiatric and public health practice in remote Indigenous communities. However, I will first demonstrate that, even as conventionally defined, mental health problems are common, and that contemporary understandings of Indigenous mental health are confused and conflicted.
Defining the problem
The existing mental health database is woefully inadequate. It is a matter of concern that the national mental health survey was undertaken in the late 1990s without an Indigenous component. The available material is from registers and service collections, data which is subject to problems of identification, categorization, attribution and interpretation. Regardless, data from the Australian Institute of Health and Welfare (Table 1) on hospital separation shows that both Indigenous males and females are more likely to be hospitalized than their non-Indigenous peers for organic mental disorders, disorders due to psychoactive substances, psychotic and mood disorders.
Standardized morbidity ratios for mental and behavioural disorders: Indigenous: non-Indigenous, 1998–1999, based on all Australian age-, sex-, and cause-specific rates. Categories are based on ICD 10, Australian modification (AIHW National Hospital Morbidity Database)
While information on Indigenous adult mental health status is poor, that for children and young people is worse, largely confined to gross measures of behavioural disturbance such as deaths from injuries, for which Indigenous males and females aged 15–24 years were, 2.3 and 1.6 times, respectively, more likely to die than their non-Indigenous peers in the years 1995–1997 (AIHW Mortality Database). Hospitalization rates for this population (Table 2) show that while Indigenous people in this age group are more likely to be admitted to hospital for injuries and violence (young women being 15 times more likely), they are no more likely to be hospitalized for mental disorders, indicating problems of functional access. This is despite a wealth of other information suggesting increased exposure to emotional and psychological traumatization, such as child sexual abuse. For instance, the Health Department of Western Australia reported that for the year 2000 the Indigenous: non-Indigenous rate ratios for notifications of gonorrhoea and chlamydia in the 10–14 years age group were 186: 1 and 124: 1, respectively [5].
Reasons for hospitalization, young people 15–24 years, Indigenous: non-Indigenous rate ratios, 1997–1998 (AIHW National Hospital Morbidity Database)
Colliding constructions
In an earlier paper in this Journal I presented an historical overview of psychiatric engagement in Indigenous mental health [6]. I pointed to the emergence of different constructions and languages to describe mental health from the 1970s. That decade stands as a watershed between a world of total control of Indigenous lives through policies of isolation, protection and, later, assimilation, and an environment that from the 1980s has been substantially less structured or accommodating of non-Indigenous impositions. During that period, as Indigenous organizations confronted and rejected what were experienced as imposed mental health categories, alternative constructions emerged. The appropriation of a socially constructed concept of mental ‘health’ (rather than what was perceived to be the ill-health focus of the prevailing ‘disease model’) was supported by increasing interest in public health approaches. The emerging constructions prioritized wellness, holistic health and culturally informed approaches to healing and were embraced by workers within the Commonwealth-funded Aboriginal Health Services. This was formalized in the Emotional and Social Wellbeing National Action Plan.
However, the Commonwealth, relatively, remains a junior player in terms of service provision. Regardless of rhetoric, interpretations at the level of State policy implementation and program planning are different. Programs which are funded through the Commonwealth use the discourse of social justice and mental ‘health’ or ‘wellness’, whereas their State counterparts continue to rely on that of services, resources and diagnoses. These usages clash at a local level in the dialogue between community-controlled health services and State fund holders regarding resources.
Stolen generations
These different usages have implications. Introducing social justice into considerations of resource allocation in Aboriginal health adds to an already complex situation in an area in which funding is limited. This is exemplified by the Commonwealth's response to the release of the Human Rights and Equal Opportunity Commission's [7] report on the removal of Indigenous children from their families. The Commission recommended a framework for reparation involving:
1. acknowledgement of the truth and an apology;
2. guarantees that these human rights won't be breached again;
3. returning what has been lost as much as possible (known as restitution);
4. rehabilitation; and,
5. compensation.
Monetary compensation, according to the Commission, is due for breaches of human rights. They also demanded improvements in mental health services and for grief and loss to be addressed. However, this should not be understood as reparation as this would trivialize by medicalizing a human rights issue. Raymond Gaita [8] touched on this issue in reflecting more broadly on understanding the reasons for reconciliation rather than sentimentalizing its symbols: Relief of the material and psychological misery of many of the Aborigines will not count as reparation, however, unless the spirit in which that relief is given is informed by a recognition of the wrongs they have suffered… Acknowledgements of those wrongs as a source of torment distinct from and not reducible to their mental or psychological consequences is, I believe, what Aborigines desire when they ask for a national apology. [p.100]
The Commonwealth's immediate response to the release of the report was the second round of funding for emotional and social wellbeing, including provisions for ‘grief and loss counsellors’. Unfortunately, debate around the social justice issues of the disruption of Indigenous family life has been medicalized and is now discussed in the language of mental health, with legal recourse for those affected being argued in terms of its consequential mental health harm rather than on the fact and illegitimacy of those acts. Ironically, the Commonwealth is thus in the odd situation of funding grief and loss counsellors to address the acknowledged mental health consequences of past policy while vigorously resisting personal or group claims on the basis of such harm or its cause.
Grief and loss is extremely complicated, compounded of reactions to personal experiences and historical events. It is also now powerfully symbolic of the injustices experienced by Indigenous people. What, then, are the implications of ‘recovery’; does a reduction in emotional pain signify a lessening of social injustice? Let me be clear. In no way do I question the wrongfulness of past policy or minimize the emotional pain – both are real, but their conflation is problematic.
I believe that the symbolic accretions resulting from this course have had unintended and significant mental health consequences in a way reminiscent of the Royal Commission into Aboriginal Deaths in Custody. While that Commission focused national attention on a range of problems and stimulated activity in certain areas, the outcomes were not universally positive. For instance, it has been argued that police concern regarding liability for an Indigenous suicide in custody led police to avoid detention at almost all costs, at times at the expense of public safety, particularly in the case of family violence (Jane Lloyd, Four Corners, ABC television, September 3, 2001). In relation to symbols and meaning, it has also been argued [9] that the media constructions of Aboriginal suicide that accompanied the Royal Commission contributed to the increase in non-custodial suicide in the 1990s.
Suicide
The images are in the National Gallery and other collections, and in graffiti and public art. In the centre of Cooktown (Queensland) stands a ceramic artwork, the ‘Milby wall’ which displays the contact history of local Aboriginal groups. The whole work is many metres long with the middle panel displaying symbols of contemporary oppression. Indigenous people are depicted at the undertaker's, the lock-up, the hospital, the courthouse and being rounded up into a paddy-wagon. The central motif is a black man hanging from a tree, a white policeman standing nearby. The accompanying text reads: The very high levels of incarceration in gaols translated to many deaths in custody. A special commission was set up to deal with this problem… The Department of Justice is working in communities and towns to bring justice and fairness to all aboriginal people.
Whatever the intent of the artist(s) the association of social injustice and hanging, and thus of hanging as symbolizing social injustice, is evident – and seen regularly by most of Cooktown's children.
Given the concerns regarding the reporting of suicide, such representations are inconceivable in the mainstream. Ironically, it is because it is Aboriginal – because it has other meanings – that such symbolism is unquestioned. Indeed, in a recent publication Tatz [4] suggests that: there could well be value in the deliberate encouragement of painting and sculptures as ‘purgation’ of suicidal feelings… In Nowra, health workers have been reasonably successful in suicide education by showing the paintings… or photographs of them, to young people at risk. Community organizations could consider a ‘paint-your-feelings’ program’ [p.205].
The dangers of this untested approach should be obvious.
I am not suggesting that individuals choose to hang themselves as a conscious act of protest; most suicides are impulsive acts in the context of heavy intoxication often following what may appear a trivial confrontation or loss. However, while suicide is ‘overdetermined’, reflecting a constellation of interacting causal factors, I believe the ‘meaning’ of such acts, reinforced by the funerary rituals and outpourings of emotion, have contributed to lowering the threshold of consideration of this act. In this setting alcohol, particularly binge drinking, can drop the bar altogether.
Well-intentioned initiatives with unforeseen consequences
There are other examples of well-intentioned initiatives that have had unforeseen consequences in Indigenous settings. I shall instance just a few which are relevant to mental health. An obvious example is directing security payments to advantage those most in need – mothers and children, the elderly and disabled. However, in environments of limited resources and immediate demands this has too often led to competition, confrontation and conflict, increasing the vulnerability of the very groups for whom the interventions were intended. A second is the financial ‘empowerment’ of councils and organizations, for instance in north Queensland, through the profits from the sale of alcohol; which thus increases reliance on the sale of alcohol and incentives to sell more grog (a major concern of the Cape York Justice Study – the ‘Fitzgerald Inquiry’ which delivered its report to the Queensland Government in November 2001). A third consequence is victim compensation. For many years now a Queensland lawyer, Tony Bailey, has been flying to remote communities across north Queensland with consultant medical practitioners lodging compensation claims for Aboriginal victims of crime, for which the Queensland Government provides awards of up to $75 000. For his services, Bailey receives payments that have at times totalled one-third of the final awards. There are quite polarized opinions regarding Bailey, exemplified by an interview with Murrandoo Yannerr on The Law Report (ABC Radio National, 20 December, 2000).
Murrandoo Yanner: There's people lining up left, right and centre, because as I say, there's thousands that have gone without justice for many years who are prepared to I suppose have a fair whack of their winnings taken out, because they're getting larger winnings. No-one likes having some of their winnings deducted, but I mean I've got some young rellies who have won awards and been like that, but I addressed it with Mr Bailey and he literally told me straight, ‘Well look, I'm going to take what I get, I'm not a charity worker, I'm going to take what my costs are out of that, and they're going to be a whack, but I'm also going to get my client the biggest payout that anyone will get him.’ And he's literally done that; I don't think anyone in the Gulf complains about the amount of awards they're winning.
Chris Richards: You thought last night that Tony was pretty mercenary about the way he operated. Do you still think that?
Murrandoo Yanner: Well yes, but I mean lots of people employ mercenaries to win a war, and it's certainly been a battle in the Lower Gulf to get victims recognized by the Queensland Government and to get them decent awards. And I wouldn't bring in a pastor or a father layman to do that sort of work. I think a cut-throat mercenary is the right bloke for the job and he's certainly proven that. Bailey's been straight to me on that, but he's not a charity case. He likes to line up his work, he feels it's got a good course, etc., but he's certainly going to get paid well for it. He sort of put that straight to me, and while I personally mightn't agree with that because I'm a real charity case, I guess not everyone is and not everyone has to be.
Chris Richards noted in the same program that: In a complaint to the Law Society in 1997, then Attorney-General Denver Beanland, complained that Mr Bailey may have represented both defendants and victims, and that this could be a conflict of interest amounting to possible misconduct. The Law Society's response seven months later: insufficient evidence of unsatisfactory professional conduct to warrant any disciplinary action.
From a health perspective this is the nub of the issue – a confusion of victim, perpetrator and beneficiary. During a recent trip to remote communities I heard of a savagely beaten woman awarded enough money to purchase a vehicle. She was again assaulted by the same person in a conflict over the vehicle and is now awaiting further compensation. Nurses have stated to me that patients have demanded to know ‘how much is this worth?’ in relation to injuries, and suggested that anticipation of greater payments may result in a delay in presentation. At least in north Queensland, the term ‘blood money’ is now being used by some community members.
Rationalizing inaction
There is also reluctance and confusion regarding enforcing standards that would be expected in the mainstream, perhaps for fear of being labelled paternalistic, perhaps because it is ‘too hard’, sometimes rationalized as accommodating cultural difference. Examples from two areas will suffice – policing and education. In terms of policing there is such focus on over-detention that police non-intervention is not generally acknowledged as a problem. But violence is common and no matter how hard it is for police to intervene in drunken family fights – it is imperative. While the overly diligent arrest of Aborigines drinking in public in tourist areas has been a justifiable cause for complaint, there is little said of failures to prosecute licensees serving intoxicated Indigenous drinkers in non-tourist areas. Another policing and health issue is seat belts – at least in the communities I visit, seat belt legislation is infrequently enforced despite the far more dangerous state of vehicles and roads. Unlicensed firearms are common. In the early 1990s there were five self-shootings by young men in the canteen of one community I visited, one of whom died. Attempts to get the police and council to act on firearms maintenance and safety failed – it was ‘too hard’.
Another area is education. At one community I visit the student enrolment is over 400. There are 22 teachers. By mid-year there are less than half the students attending and substantially lower later on. At times there will be less than 50 students at school. This is not just about schools failing to enforce attendance, it is also about internal issues, as David Martin [10] notes: ‘Such practices arguably reflect continuities in child-rearing practices as much as they do social breakdown… It is rare for even a senior individual to be able to exercise authority across all members of a family’ [p.15]. However one allocates responsibility the result, as Peter Sutton [2] notes is a ‘lost generation’ of: ‘Young people who, unlike their grandparents, are functionally illiterate and unemployable in the “real economy”, but who have also received only a diminished education in their elders’ cultural traditions, if that…’ [p.12].
Of course, the relationship between health and education hardly needs emphasis; there is now a rich lode of data internationally and in Indigenous Australia. For example, in a historical study comparing infant mortality rates and failure to thrive across Far North Queensland Aboriginal communities after the Second World War, after considering household size, employment and the proportions of the various populations who had not attended school, researchers found that: ‘Only the measures of education are significant: the smaller the proportion of women and men without schooling, the lower the infant mortality’ [11], p.7]. A more recent example is an analysis of 672 births to Indigenous women in Brisbane between April 1996 and September 1999 [12]. A relationship was found between maternal educational attainment and intrauterine growth retardation (IUGR), with 35% of mothers with less than grade 10 education giving birth to a child with IUGR as compared to none among those with post-secondary education.
An ‘ounce of prevention’
All of the above are consequential for mental health as a result of the impact on individual behaviour. However, they have far more damaging and enduring consequences by contributing to the developmental environment – including pregnancy. Thus the appeal of prevention which has, over the last half-decade, received significantly more attention, particularly with the Mental Health Promotion and Prevention National Action Plan [13] within the Second Mental Health Plan. In this, as well as the national suicide prevention and crime prevention initiatives, a developmental (life-span) perspective has been adopted with Indigenous Australians identified as a priority target group in each. In addition, there is increasing attention given to the social determinants of health and activities that are now subsumed under the rubric of ‘capacity building’.
Mental health promotion and prevention is a recognized priority in Indigenous settings. This is understandable given the abundance of potential areas for prevention and the appealing logic of the dictum: an ounce of prevention is worth a pound of cure. However, that needs to be put in context. When that folk-wisdom originated in late nineteenth century European societies, there was precious little cure, and diseases were receding (being ‘prevented’) largely due to broad social changes. The ability to ‘cure’ came later. In Indigenous Australia probably the single most important health improvement was the dramatic reduction in infant mortality that occurred through the 1970s which resulted, primarily, from the extension of health services and antenatal care to Indigenous communities. The Indigenous infant mortality rate remains some two- to three-times higher than for non-Indigenous Australians – the issue now is not physical service access, but much broader lifestyle and social issues. That is much harder to address.
Furthermore, the major revolutions that have transformed mental heath have been enabled through improvements in treatment – antibiotics for syphilis at the beginning of the last century, traditional antipsychotics and lithium in the 1960s and 1970s, and more recently the development of medications that can treat without disabling or stigmatizing, allowing patients to return and be part of a community rather than just ‘in’ it. Mental health promotion and prevention is in its infancy and has been supported in the mainstream because effective treatment services are available. The enthusiasm for embracing mental health promotion and prevention in Indigenous settings must, I believe, be tempered. By and large, we do not have those basic treatment services available. I am aware of situations in which there are no clinical services but where designated workers (funded through mainstream services) indicate that their role is ‘promotion and prevention’. This is in the face of enormous immediate clinical demands for work that is neither easy nor sexy – that is, working directly with the crazy, depressed, alcoholic and otherwise demoralized. I contend that, as was the case with infant mortality, the most important mental health promotion and prevention work that can be undertaken in Indigenous communities – from the mental health sector – is to provide accessible and acceptable services to all Indigenous communities. That done, there is a structure through which to address wider needs, and the priority in that regard is the environment of child development, which will demand working with other sectors.
This is not to say that the ‘big picture’ issues should not be a priority. They should, but they are beyond the sole means of the health, let alone the mental health sector. I believe that there are dangers in prioritizing such agendas if it is at the expense of basic service provision. Exclusive preoccupation with the ‘big picture’ agenda has dangers, as Leonard Syme [14] notes: insisting only on fundamental and revolutionary social change is dooming us to programs that will take years and generations to take effect. Since it is difficult to implement such major social change, it is easy to ignore inequalities because, they say, nothing can realistically be done about them. Moral outrage about inequalities is appropriate but may be self-indulgent. If we really want to change the world we may have to begin in more modest but practical ways. [p.9]
As a psychiatrist working in Indigenous Australia I believe that mental health professionals need to focus on those modest but practical clinical ways. I am also a public health physician, and despite the foregoing have a real conviction of the importance of mental health promotion and prevention. I can see opportunities and recognize some critical immediate challenges that must be addressed – fetal alcohol exposure is perhaps the most pressing. I have just visited one community and was consulted regarding three males between 13 and 16 for whom fetal alcohol exposure is proposed by various specialists as a basis for their intellectual impairment and disabling behavioural problems. Two have been arrested for sexual offences – one of extreme violence. The third has been treated for syphilis. The community has no idea of how to respond to these issues. At the moment – neither do I.
Levels of responsibility
‘Big picture’ issues are important but beyond the capacity of the health sector alone. Progress at that level will demand a whole-of-government approach; in this I agree with Noel Pearson. I also believe that, notwithstanding the human rights abuses and injustices of the past which must be addressed at a national level, communities and families must be empowered to take their measure of responsibility for the abuses and injustices that are currently perpetrated on the most vulnerable. These include fetal exposure to high levels of alcohol, and the physical and sexual abuse of children. Certain Indigenous leaders are now demanding such responsibility (for instance Ted Wilkes, Director of the Aboriginal Medical Service in Perth, on Four Corners, ABC television, September 3, 2001). But it is a complex, divisive and profoundly painful process, as Victoria Laurie and Colleen Egan found in investigating the sexual abuse and subsequent suicide of a 15-year-old Aboriginal girl in a Perth fringe community (‘Susan's story’. The Weekend Australian Magazine, December 15–16, 2001, 38–43).
In attempting to better understand ‘responsibility’ I have previously drawn from the Holocaust studies literature. Several concepts have been useful in understanding non-Indigenous responsibility for traumatization, leading to papers with a focus on the roles of medical professionals. An obvious example is denial, specifically, non-Indigenous denial, rationalization and trivialization of the injustices to which Aboriginal Australians were exposed [15]. Another is the typology of perpetrators, victims and bystanders to trauma which, in the Holocaust context refers to the Nazis and their functionaries as perpetrators; Jews, Gypsies, the mentally ill and others who were identified for elimination as victims; and, perhaps most complicated, as bystanders a range of groups including the wider German population, fascistsympathetic and anti-Semitic other nationals, and, it is contended, even Allied military planners who refused to be distracted from strategic military ends despite awareness of the horrors unfolding in Poland and elsewhere [16]. It is not hard to see how this typology might apply to the oppression of Aborigines as a people or, indeed, the roles of health professionals in Indigenous Australia. I have argued that ‘medical professionals must not presume some privileged neutral space outside of the historical process’ [17]. Within that process doctors were, at times, perpetrators through complicity in discriminatory and harmful policy and practice, victims by virtue of the replacement, for some, of idealism with fatalism, and often bystanders, taking in only fleeting glimpses of the major currents of hurt and harm in communities from the hermetic safety of the clinic.
However, there is also a literal application of this typology of perpetrators, victims and bystanders of violence in Aboriginal communities. While such intracultural violence can only be fully understood in an intercultural social and historical context [18], in what follows I will focus on the Indigenous bystander. Readers who have lived in remote communities may be aware of episodes of violence in which opportunities for intercession by Aboriginal community members were not acted on. I am, and while I can understand how the disempowerment of Aboriginal people as a whole may have contributed, I am also aware that this was not the case in the past – there were brakes and social safeguards [19]. There was violence – but there were also limits, and ‘minders’ who would step in when those limits were transgressed.
Thus, the third concept from Holocaust studies comes from an investigation of the bystander. Norman Geras [20] has explored this and coined the term a ‘contract of mutual indifference’ in which, he proposes: If you do not come to the aid of others who are under grave assault, in acute danger or crying need, you cannot reasonably expect others to come to your aid in similar emergency; you cannot consider them so obligated to you. Other people, equally, unmoved by the emergencies of others, cannot reasonably expect to be helped in deep trouble themselves, or consider others obligated to help them. [p.28] doing nothing for others, they cannot reasonably expect to be helped in extremity themselves or consider others under obligation to help them. It is as though they agree by their own inaction to forego any expectation of help they might otherwise entertain. They waive any right to help they might be thought to possess. [p.37]
Under these conditions the unstated and usually implicit contract of mutual assistance – I come to your aid in expectation that, were the situation reversed, you would provide aid to me – is abrogated; instead, Geras proposes – you are absolved of any requirement to give aid as long as no such demands can be made of me. The potential consequences of ‘getting involved’ outweigh the ‘insurance’ benefits that assistance could provide – a scenario that probably sounds familiar to residents of poor, violence-prone inner-big-city neighbourhoods – ‘don't get involved!’ So why consider this in even more socially disadvantaged Indigenous communities? Because it doesn't seem to have been the case even up to relatively recent times and because alcohol-related violence has and continues to increase alarmingly. And because I'm struggling to understand these and other changes in relationships and responsibilities in the communities I visit. Seven years ago I wrote a letter on behalf of a patient, a woman from a non-drinking family whose anxiety related to the demands made by drinking relatives – the complexities of ‘demand sharing’ [21] in a non-traditional cash economy. She was concerned about violence and wanted to surround her house with a lockable cyclone fence. I wrote the letter and the fence duly appeared. I recently returned to this community after an absence of five years. Cyclone fences are now commonplace.
My letter was sent with the best of intentions. However, while much harm has resulted from past policies and actions that were inconsiderate of effects on Indigenous people, much, perhaps even more harm has flowed from policies and programs that were well motivated but which had complex and unanticipated consequences in Aboriginal communities. Single mothers do require particular consideration but single mothers’ benefits have impacted on the durability of relationships and, thus, parental unions. Owning alcohol outlets has provided economic benefits to communities, but with very obvious human costs. Victim compensation goes some way to redress harm done, but may be contributing to victimization. Within health, mass recruitment to Indigenous health positions and rapid advancement has gone some way to redressing the inequities in health staffing, but often poorly trained and supported, this has, at times, backfired on both the organizations and the Indigenous workers. Rejecting ‘outreach paternalism’ and demanding or expecting that communities and residents will necessarily be ‘responsible’ for their health supports autonomy; it can, however, leave the most disadvantaged and least capable adrift. Within mental health the rapid appointment of grief and loss counsellors after the Stolen Generations report is understandable. Without recurrent funding, often with little training or support, and confronted by enormous mental health needs, their impact is often questionable. The enthusiasm for mental health promotion and prevention brings attention to social determinants, but at a real cost if it detracts from efforts to ensure access to basic clinical services.
There is no going back and the courses taken may have been unavoidable. But we are doomed to repeat mistakes if we do not reflect critically, regardless of initial intent. This includes reconsidering some cherished ideals and sacred cows. While mental health professionals have a small role to play in the larger project of Indigenous health and wellbeing, it is an important role and we need to be clear about the limits of our own capacities and responsibilities. Seven years ago I published an article under the title ‘Is there a role for prevention in Aboriginal mental health?’ [17], I believed then and do now that there is, but I would add that in this capacity mental health practitioners need, first and foremost, to get their primary role – delivery of mental health services – in order. We need to be mindful of the big picture and supportive of initiatives in that arena, but remain focused on the ‘modest but practical ways’ for which our training prepared us.
To summarize this meandering course, I have pointed out that mental health practitioners have only recently engaged in a sustained way in addressing Indigenous needs. Two quite different constructions have emerged; fairly conventional mental health, the ‘disorder model’, on the one hand, and emotional and social wellbeing on the other. These constructions have consequences in terms of tensions relating to areas of responsibility and resource allocation. Regardless of how it is defined, it is clear that the burden of serious mental illness and mental health problems is heavy, particularly in remote Indigenous communities, and that clinical service access is poor.
Conclusions
Acknowledging and integrating past human rights violations into our national history is a necessary but difficult ongoing process that is complicated rather than clarified by the medicalization of social justice issues, as in the mainstream response to the Stolen Generations report. The way in which such complex issues are constructed is consequential in many ways some of which, for instance the representation and symbolism of suicide by hanging, may have untoward effects. Indeed there are now examples of very well-intentioned initiatives that have had unforeseen negative consequences when implemented in Aboriginal settings.
Within the mainstream mental health sector there has been a long-overdue investment in mental health promotion and prevention. However, even with a substantial clinical service base as a foundation and with various degrees of intersectoral commitment, this has not been without problems. In Aboriginal settings the goals and ideals of this broader vision are very appealing and consistent with that of holistic constructions of health. But the context is very different in that a firm foundation of clinical (and most other) service delivery does not generally exist. Attempting to deal with these enormous issues from within the health sector alone, or prioritizing such elusive goals over the development of core service activities, risks initiating non-sustainable activities and disadvantaging Indigenous people with serious and immediate mental health needs.
Noel Pearson [1] is right in calling for a whole of government approach. He is also right in pointing out that there are different types of traumatization and that, even as collective healing proceeds, the personal traumas of contemporary life need to be addressed. He has also suggested that the transmission of traumatization from one generation to another is reinforced by processes put in place to alleviate disadvantage – ‘passive welfare’. This includes problems that have emerged in very recent times, including child sexual abuse. Furthermore, he notes that: ‘What has to be remembered – particularly in a society that has been gripped by a passive welfare mentality – is that people will resist responsibility’ [p.58]. Indeed, the title to his monograph is ‘Our right to take responsibility’.
Responsibility relates to another term used by Pearson – ‘mutual obligation’ [p.86]. I have touched on my own confusion in attempting to understand how mutualilty has appeared to me, to have become less salient in the Indigenous communities I visit, at least in relation to intentional harm. In doing so I specifically raised the issue of the bystander, and the ‘contract of mutual indifference’, a theory derived from the very different circumstances of the bystander in the Holocaust. The term genocide is now used in relation to the removal of Aboriginal children from their families. From the safe vantage of the 21st century our forebears are often held responsible despite their claims that discriminatory policies and activities were undertaken with best intentions. However, I don't think it implausible that 50 years from now current members of the ‘helping industries’ for Aboriginal communities, what the late David Mowjaljarlai referred to as an ‘industry of despair’ (Susanna Lobez, The Law Report, ABC Radio National, 20/12/00) will be held similarly accountable, and our response may sound equally lame.
Finally, while non-Indigenous mental health practitioners must be more mindful of appropriate ways of working, they have a primary responsibility to deliver a service to Indigenous communities and, as yet, we have not lived up to that responsibility. In terms of the larger social agenda and mindful of untoward outcomes of well intentioned past approaches, I think Peter Sutton [2] is raising a difficult but important issue when he suggests that:
everything, including the question of artificially perpetuating ‘outback ghettoes’ or other similar bureaucratically maintained institutions, the encouragement of corporatism as against the pursuit of individual needs and aspirations, de facto laissez-faire policing policies with regard to Indigenous community problems of violence, petrol sniffing and drug abuse, even separate Indigenous service delivery, should be all on the table. [p.2]