Commentary on Black et al.,a systematic review: Identifying the prevalence rates of psychiatric disorder in Australia’s Indigenous populations

The recent systematic review by Black et al. (2015) highlights a number of issues regarding the state of research on mental illness in Aboriginal and Torres Strait Islander Australians. The dismally low number of papers identified by Black et al. points to the fact that little research has been conducted in the area. The review reveals the need for both culturally competent validation of diagnostic tools and more consistent methodological approaches to prevalence studies conducted in Aboriginal communities. However, more pressingly, there is a need for greater critique of the theoretical frameworks underpinning programme evaluations. Revisiting these frameworks may offer new ways of engaging and working with Aboriginal communities to shape understandings of mental illness experienced by Aboriginal peoples.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD) are Western classification systems, and the transferability of these criteria into Aboriginal contexts is questionable. Professor Arthur Kleinman, noted Harvard academic, reminds us that classifications systems such as these are a guide to be used with caution. Clinicians should always utilise the resources available to them, and first and foremost, they should always apply the principle of do no harm. In particular, culture should never be underestimated or ignored in determining the presence and severity of mental illness.

Alex Brown’s work (Brown et al. 2013), for example, goes some way to validating diagnostic instruments in partnership with Aboriginal communities and opens up a new landscape in which to investigate the nosological challenges faced by psychiatry. If we are to view research as a means to an end, we must begin our questions at their source; the origins from which we formulate our research questions represent the worldviews with which we see and experience the world around us. The suggestion made by Black et al. that the Australian Bureau of Statistics (ABS) Australian Health Survey (AHS) scheduled for 2018 incorporate questions relating to mental health in addition to physical health is in itself a valid one. However, it does not necessarily further our understanding of the cultural perspectives inherent in Aboriginal peoples’ experiences of and understandings about mental illness, particularly given the diversity of Aboriginal peoples in Australia.

The Looking Forward Aboriginal Mental Health Project undertaken in Perth, Western Australia (Wright et al., 2013a, 2013b; Wright and O’Connell, 2015) further attempts to address this very question. How can we bring about systems change through a better understanding and acknowledgement of Aboriginal worldviews in relation to the ways in which Aboriginal clients and their families access mental health services? And how can service providers more effectively respond to Aboriginal clients and their families with greater attention to the cultural and spiritual dimensions of their lives? The Project seeks to develop ways for services to engage with Aboriginal people by bringing them together with local Elders to create new ways of working in collaboration with the local Aboriginal community in the Perth metropolitan area. For mental health and drug and alcohol service providers, developing a working understanding of a Nyoongar ¹ worldview is central to the change efforts they undertake alongside the community.

We believe that the Looking Forward Project is a direct challenge to the mental health system, not by researchers but by the participants, that is, Nyoongar Elders and service providers, together. We are very confident that change will occur, for we are witnessing such change emerging in the governance and practices of these organisations. What has become clear in our work is that attempting to fit Aboriginal worldviews and experiences of mental illness into the mainstream system is unlikely to be successful. This approach is itself a contributing factor that excludes Aboriginal peoples from receiving meaningful and appropriate mental health services.

Our findings have shown that when non-Aboriginal practitioners are open to and accepting of a Nyoongar worldview, the shift in their intention is profound. This in turn becomes an intention shared with the Community, an intention to change the system that continues to disenfranchise and in many instances re-traumatise Nyoongar clients and their families as they attempt to interface with it. This is a new paradigm for working shaped by the Nyoongar Elders who have wholeheartedly taken up the opportunity to drive the change.

Engaging with Aboriginal communities in this way fundamentally reframes our methodologies and challenges classificatory processes. This is the pivotal challenge of our research work. It undoes the fabric of our methodologies and casts aside the paradigms on which we form our hypotheses. Yet it is necessary, indeed essential, if we are to close the gap on health inequalities experienced by Aboriginal peoples and in particular the provision of mental health services.

See Review by Black et al., 49(5): 412–429.