‘Country giving you a thing of it’: Elder-governed cultural therapy for Indigenous young people

Introduction

Indigenous young people globally suffer poorer mental health outcomes than their non-Indigenous peers (Close the Gap Campaign Steering Committee for Indigenous Health Equity, 2018). A 10-year review of the Close the Gap Strategy identified that disconnection from Country and culture has been a crucial factor. Physical and mental health cannot be separated from spiritual health and well-being among Indigenous Australians. Likewise, spirituality remains central for health and well-being in Native American and Canadian First peoples, manifest through closeness to the earth and harmony with complex environmental ecosystems (Marsh et al., 2015). Cultural revitalization linked with decolonizing practices enables health and well-being. In Australia, Dudgeon et al. (2017) propose strengths-based spiritual healing practices, self-determined by Indigenous peoples to counter ‘white patriarchal ethnocentric norms’. From a clinical perspective, Tseng (2006) articulates that culture may influence the formation of mental disorder, give rise to the coping styles to deal with stress linked with mental disorder, modify the clinical presentation of mental disorder, affect the severity and frequency of mental disorder and shape its management.

Recently, Hartmann et al. (2022) warned against incorporating Indigenous cultural knowledge and practices into mental health service delivery because of the potential for further harmful colonization. Rather, culturally supported Indigenous practices should be offered alongside mental health management (Asamoah et al., 2023). At present, the majority of Indigenous Australians live in urban centers with mental health care delivered via hospital inpatients and outpatients that are often perceived as alienating and distressing places (Dwyer et al., 2011). Hence, we aimed to develop an Elder-governed cultural therapy (CT) that arises from Indigenous Spirituality in varied forms and is delivered by Indigenous mental health practitioners for Indigenous young people and their parent/guardian who are clients of a Western tertiary/quaternary hospital. Moreover, the CT will occur alongside Western mental health care but separate from it and the hospital. Vance et al. (2024) provide a comprehensive description of our method while this paper outlines the details of CT that we developed.

Methods

The clinical research protocol was Hospital Ethics Committee approved (2019.207/56941). All participants and their caregivers were given verbal and written information, and written informed consent was obtained from each participant’s caregiver. First, we established a Board of Elders and an Advisory Group of Indigenous health workers. Elder governance of cultural projects is a protocol that is consistent with how Indigenous communities work, nationally and internationally (Vance et al., 2024). Elders maintain a central and core role, mediating and leading all aspects of Indigenous communal life, directly and indirectly. They enable deeper connections between people and with Culture (Vance et al., 2024). The Indigenous Advisory group provides additional guidance on navigating Western health care systems while maintaining cultural authenticity. Second, we completed 44 community yarns with a representative group of Elders, healers, senior and junior people involved in health and well-being of the Victorian Indigenous community (see Table 1). The yarns teased out what culture means for each person and their community, how culture aids and/or maintains health and well-being, who best governs cultural practices in their community and what practical issues need to be addressed for cultural practices to be put into place for hospital clients. Third, we developed a culturally appropriate method of analysis: a multi-perspectival, discursive, constructivist approach to ensure the participants’ experiences drove the findings and all voices were recorded (Vance et al., 2024). Finally, from what we have learned through the community yarns we developed an adjuvant model—CT led by Indigenous health practitioners to trial with young Indigenous participants with mental health conditions referred to an urban hospital outpatient setting.

Table 1.

Participant characteristics for the 44 community needs assessment yarns.

	Northern Vic	Southern Vic	Eastern Vic	Western Vic
Males, Females	8,9	4,5	4,5	4,5
Urban, rural	9,8	3,6	5,4	4,5
E/H/SP/JP	6,3,5,3	4,1,3,1	4,1,3,1	4,1,3,1
Tribe	17	22	20	21

Northern/Southern/Eastern/Western Vic: region of Victoria, Australia; Urban: metropolitan living, Rural: country town or farm property living; E/H/SP/JP: Elder/Healer/Senior Person/Junior Person working in health and well-being field in Aboriginal Victoria; Tribe: tribal affiliation of participants (commonly multiple groups).

Results

CT as an adjuvant therapy is delivered by Indigenous mental health practitioners (nurses, social workers, psychologists, psychiatrists) for Indigenous young people and their parent/guardian who are clients of a Western tertiary/quaternary hospital. It is informed by Indigenist epistemologies and ontologies which affirm that Indigenous peoples’ worldviews are distinctive and vital for their existence and survival (Dudgeon et al., 2017) and ‘two-eyed seeing’ which seeks the best from both Western and Indigenous models of health (Bartlett et al., 2012). Oversight is provided by a governing board of Elders and CT is financially supported by a national program grant.

Each Indigenous young person and their guardian work with an Indigenous Cultural therapist (a mental health professional) under the guidance of the Elders’ board to explore a place-based cultural practice that takes a variety of forms: art, music, dance, animal-assisted therapy or walking in Country. CT is particular to the therapist and participants, reflecting the different perspectives, skills, roles and priorities they have. However, the form of CT is generalizable. Reflective, narrative and dynamic interpersonal processes and mutual co-learning built on respect are its hallmarks. In addition, CT is iterative, fostering internalization of coping styles and interpersonal skills in Indigenous young people. A crucial element of CT is an invitation to the young person and their guardian to participate in a cultural practice that is integral to the therapist’s own life, so the practice is an authentic and congruent expression of lived epistemologies and ontologies. The Cultural therapist, young person and their guardian engage in CT together as a relational community of Indigenous people. All are expectant of revelations from Country, community and the spirit world of how to live connected and fulsome lives. Each—therapist, young person and guardian alike—then share what they have discerned, reflect on the revelations together and make meaning from it for each young person and their guardian.

CT involves approximately 8 hours delivered over six sessions. At the conclusion of CT, agreed themes particular for each young person are inscribed on a message stick, made from sacred sandalwood (Cherry Ballart) prepared according to cultural protocols for the Country from which it comes. This message stick is given in the last session to the young person as a physical summary of the journey they have been on and a tangible reminder of their cultural connections, insights and all they have learned.

Discussion

Western health practitioners can work with Indigenous mental health practitioners and the Indigenous communities from where their patients come to implement CT. To date, we have begun to evaluate CT by enrolling 15 randomly selected Indigenous young people with mental health disorders and their families looked after through the Indigenous Health Liaison Unit where the study is underway. All continue to receive Western mental health bio-psycho-social management while they receive CT. Pre-therapy, immediate post-therapy and 3-month follow-up yarns are conducted with the young person, their guardian and their therapist. The Indigenous research assistant who accompanies the participants in every therapy session is also writing their own cultural reflections. As with the CT design phase, a multi-perspectival, discursive, constructivist, grounded theory research methodology is used to analyze these yarns (Vance et al., 2024). The initial results are very promising focused on themes of improved connection to Country, community and strengthened Cultural identity. In future, we aim to provide CT to 30 such Indigenous young people and their families and then publish the completed evaluation. In this way, Indigenous communities that often distrust Western research and believe Western mental health care is ineffective for their members can be engaged. It has the potential to shape future clinical health service delivery policy for Indigenous young people with mental health conditions as an adjuvant management.