Cultural ‘Inclusion’ or Institutional Decolonisation: How should prisons address the mental health needs of Indigenous prisoners?

A recent report Keeping Our Mob Healthy In and Out of Prison (Halacas and Adams, 2015) detailed the shortage of culturally appropriate mental health care available to Aboriginal people in custody. While it is important that these critical gaps in service delivery are documented and emphasised, this particular issue is not a new phenomenon. The capacity of mental health workers to confidently engage, interact with and proficiently assess Aboriginal clients is currently inadequate. The longstanding dissatisfaction of Kooris in custody with culturally insensitive mental health service provision is similarly outmoded information. An intense mistrust of the ‘system’ and by extension, mental health services prevails; the perception of service provider racism subsists and ceaseless criticisms of clinicians ignorant of or incapable of understanding and handling aboriginal specific issues such as grief, disconnection, powerlessness, discrimination and intergenerational trauma endure. Again, these examples are not revelations, but are seemingly immutable attributes of a system ineffectively delivering equitable mental health care to people who have already faced long periods of social injustice. The unaddressed health needs of Aboriginal people subject to the criminal justice system are well documented (Heffernan et al., 2014) and have deleterious consequences. Whether these dilemmas are suitably acknowledged or well understood by both non-Aboriginal clinicians and the associations that represent them is unclear. However, the emergence of Reconciliation Action Plans and Aboriginal health frameworks and strategies across various health and government sectors are positive steps forward in addressing pervasive inequities and improving the mental health and wellbeing of Aboriginal offenders in custody and in the community. The recommendations in such frameworks stress the need for greater partnerships with the Aboriginal community, the hiring and retention of more frontline Aboriginal health professionals and improved transitional care and cultural training for non-Aboriginal staff. However, whether such reports and frameworks will lead to demonstrable change remains to be seen. The Royal Commission into Aboriginal Deaths in Custody outlined similar recommendations back in 1991. The fact that ‘new’ reports are releasing similar recommendations to those proposed 25 years ago either demonstrates ongoing systematic unresponsiveness or ineffectual responses to recommendations. Teasing out the reasons for this apparent inactivity is complex and necessitates closer analysis.

Aboriginal mental health initiatives are often afflicted by absences of program fidelity, long-term institutional support, ongoing funding, cross-organisational communication and appropriate evaluation (Dudgeon et al., 2014). Generic mental health services face additional difficulties as providers grapple with Aboriginal conceptualisations of mental health. Few attempts have been made to remedy this widespread deficit despite regular feedback that Aboriginal clients prefer services attuned to their cultural needs. Efforts to systematically educate forensic mental health workers in cultural competency and arrange for culturally tailored therapeutic programs are typically hindered by both institutional constraint and an unavailability of appropriately resourced cultural service providers to deliver intensive training of the magnitude required. When cultural training for non-Indigenous health staff has been rolled out, it is often ephemeral, impractical, and it is not made clear to staff as to why and how such training is necessary. When offender rehabilitation programs tailored to Aboriginal clients are ‘implemented’, they are often inconsistently presented, unavailable to numerous clients, fragmentary and rarely afforded ongoing institutional support. Poor implementation in these circumstances is unlikely due to ineffectual programs with unrealistic objectives. It is a likely reflection of the shortcomings and culture of the institutions responsible for prisoner health and wellbeing.

The lack of improvements in health outcomes may well suggest that unless there is institutional reform and better capacity for programs to carry out their functions effectively, then service delivery on the ground may continue to fall short. So what must be done to ensure that similar recommendations will not be re-written in future reports 25 years from now? Part of the answer may lie with the fact that both justice and health organisations are often mono-cultural institutions, where decision-making and structural arrangements are grounded in western principles and western conceptualisations of health, law and the family. The exclusion of Aboriginal worldviews at this level renders the maintenance of inequitable power relations and an institutional inability to systematically accommodate Aboriginal knowledge. While there is a growing appreciation that Aboriginal people should ultimately be cultivating and delivering frontline services for Aboriginal clients, few Aboriginal people are in positions of influence or power in organisations where they have the capacity to be involved in making key decisions concerning the allocation of resources, diversity employment schemes, programme rollout and evaluation and cultural competency training. Without the systematic accommodation of Aboriginal worldviews, institutional racism, inadvertent or otherwise, will likely continue. Organisational decisions will be viewed by Aboriginal people as ‘made to us’ and not ‘made with us’, by us’; partnerships with Aboriginal stakeholders will remain at the mercy of the organisations volition; Aboriginal people will continue to be hired with a view to cater to other Aboriginal people and not the general population precluding executive career advancement; cultural competency training for non-Indigenous staff will remain staggered and Aboriginal programmes and mental health services will continue to be tokenistically delivered as ‘special interest’, ‘add-ons’ or general services with a cultural ‘tweak’. The decolonisation literature denotes how white privilege can permeate an organisation’s values impacting power relations and fashioning policies that may unintendedly maintain subjugation (Sherwood, 2009). This notion will persist and continue to imperil Aboriginal people in custody unless systematic transformation is realised.

What must transpire to unravel this state of affairs? One major strategy is that change must inaugurate at the executive level. A top down commitment to diversity and reflexivity facilitates organisational-wide cross-cultural cooperation. This has been described as the unbuilding of racism. Presently, organisations will often briefly engage (if at all) with Aboriginal communities before making decisions for them. These collaborations are well intentioned, but often perfunctory and unproductive. In a culturally competent organisation, Aboriginal governance and knowledge would already co-exist so that decisions are framed and effected through Aboriginal lens. Until the organisations responsible for the shared duty of mental health care to Aboriginal prisoners ‘decolonises’ itself, the objectives and targets of the various frameworks, health strategies and Reconciliation Action Plans will continue to fall short. Unless organisations are systematically able to appreciate how privilege is inseparable from ‘best interests’ decision-making, then Aboriginal self-determination in this space will remain shackled. Until institutions fully incorporate cultural knowledge, services responsible for prisoner mental health and wellbeing will continue to be culturally unsafe.

Such proposals may be sceptically viewed as dramatic, unnecessary or organisationally cumbersome. Yet without such action, Aboriginal prisoners will continue to be denied their inalienable right to equitable mental health care that meets their needs. In recent history, Aboriginal people have endured the forced removal of children from parents, cultural genocide, pervasive discrimination and removal from traditional lands. The unique traumas possessed from these events require sensitive support in a culturally safe environment, free from Western partiality. It is important to reflect on power imbalances that are invisible to those with white privilege or unquestioned, normalised positions of influence and how this impacts on groups with limited social capital. Carnes (2011) fluently asserted ‘non-Indigenous privilege permeates insidiously at even every day levels’ (p. 9). Equitable prisoner mental health care is still elusive. Organisational transformation must precede any further recommendations.