Evaluation of a culturally safe social and emotional well-being programme: a protocol

Abstract

Transgenerational trauma continues to have detrimental impacts on Indigenous Australians. However, Indigenous Australians have always recognised that the healing from colonisation’s traumatic policies lies within culture. As such, there is an urgent need for community-driven culturally safe, well-being support, particularly for Indigenous young people. The development of an adventure-based Indigenous therapy programme aims to support and improve emotional and social well-being for Indigenous young people in North Queensland. We aim to evaluate this novel programme using validated and modified mental health tools and yarning. Analysis of the data will measure the direct impact of the programme; how past traumas influence the healing process and assess the use of modified culturally appropriate mental health tools. An evaluation with culturally appropriate recommendations will be produced from the analysis. Importantly, a strengths-based approach will be followed to identify levels of resilience and positive cultural experiences existent in communities.

Introduction

The atrocities of massacres, forced removal from lands, disconnection from Country and kin, language and culture, slavery and stolen children continue to affect generations of Indigenous peoples by way of transgenerational trauma (Nogrady, 2019). Colonisation and the policies of administration has had detrimental impacts on Indigenous Australians. Indigenous peoples have always recognised that the healing from colonisation’s traumatic policies lies within culture. Emerging studies in this area state that cultural engagement in intervention programmes shows the greatest success in healing intergenerational trauma (Simpson et al., 2020).

Social and emotional well-being

Indigenous young people can experience stresses and challenges around minority group status, discrimination, racism, socioeconomic deprivation, poverty, unemployment and inequalities in health systems (Calma et al., 2017; Dickson et al., 2019). In turn, these challenges can lead to mental health problems such as depression and substance use (Jorm et al., 2012). These stresses and challenges can lead to lower social and emotional well-being (SEWB), heightened mental illness, high incarceration, substance abuse prevalence and incidence and suicide, which is now the leading cause of death for Indigenous young people (Australian Institute of Health and Welfare, 2022). Social and emotional well-being is defined as “a multidimensional concept of health that includes mental health, but which also encompasses domains of health and wellbeing such as connection to land or ‘country,’ culture, spirituality, ancestry, family, and community” (Gee et al., 2014, p. 55). Given the plethora of research in this area, there appears to be few culturally relevant and safe Indigenous programmes addressing Indigenous young people’s SEWB (Black et al., 2023). It is well documented that Aboriginal and Torres Strait Islander peoples feel safer accessing health care options that are designed and run by Aboriginal and Torres Strait Islander organisations, rather than accessing mainstream health services (Harrison et al., 2019; Panaretto et al., 2014). Indigenous-led mental health programmes and assessments that are culturally relevant and culturally safe for Indigenous young people to access are desperately needed. It is also noted, however, that Indigenous young people may be hesitant to seek help or engage in traditional treatment modalities (Rickwood et al., 2007), hence a more youth-friendly, culturally safe programme is required. As such, an adventure-based Indigenous therapy (ABIT) programme was developed to address the high rates of SEWB problems in Indigenous young people.

Adventure therapy

Adventure therapy (AT) can be defined “as a physical activity requiring some risk, with therapeutic intent, engaging with natural outdoor environments involving at least two people” (Pringle et al., 2022, p. 2). Adventure therapy varies considerably in style and method, and efficacy is known to be difficult to assess through randomised controlled trials (Gabrielsen et al., 2015). Although coercive approaches to AT are criticised (Harper et al., 2021), AT has been shown to have long-term positive impact on mental health measures (Bowen et al., 2016; Fernee et al., 2021; Gabrielsen et al., 2019). Human rights-based and complex trauma-informed adventure therapy (CTIAT; Pringle, 2024) rejects coercive treatment and adapts a clinical three-phased approach prioritising safety, before processing and integrating the experiences for improved functioning (Cloitre et al., 2011; Kezelman & Stavropoulos, 2019). Given the issues of forced removal from land, family and kin, it seems appropriate for Indigenous young people. The CTIAT framework (Pringle, 2024) has an evidenced theory and practice framework that is adaptable to ABIT. Further, this approach employs holistic assessment and application of ecological elements (Brymer et al., 2020; Immonen et al., 2022) which also seems appropriate for ABIT although little research has involved Indigenous youth.

The CTIAT framework is the result of a doctoral thesis (Pringle, 2024). Within an ecological dynamic approach emphasising the practitioners’ sense of self, CTIAT has three elements that work together with continuous pragmatic assessment and adjustment. This ensures that CTIAT is reflexive to unfolding situations and is, therefore, a framework rather than a manualised model. The framework, adapted from the study by Kezelman and Stavropoulos (2020), has four phases taking a participant from (a) safety and stabilisation through (b) processing new and positive experiences to (c1) integration of healing experiences into their future while on programme and (c2) maintaining integration after the programme ends. In each phase, participants encounter the experience, according to the phase’s theme, through five domains: activity, social, nature, aspects of time and the individuals’ connection of mind with these domains. At all times, the CTIAT framework encourages practitioners to seek improvements in the participants’ attachments, schemas, stress management and skills. Informal field trials have shown that the framework is relatively easy to understand, implement and provides some process reliabilities for practitioners.

Regarding the efficacy of AT, the Bowen et al.’s (2016) study evaluated a Wilderness Adventure Therapy (WAT) programme based on participants’ self-reported mental health outcomes (Bowen et al., 2016). Moderate, statistically significant improvements in psychological resilience and social self-esteem were observed following the programme. At the 3-month follow-up, suicidality had significantly improved. There was also a significant reduction in depressive symptomology and these changes were observed at the 3-month follow-up. These findings indicate that WAT is an effective therapy programme and a larger cohort would extend these findings. The ABIT programme has the potential to combine the positive evidence of AT, WAT and Bush Therapy, with Indigenous cultural immersion programmes. Adventure-based Indigenous therapy encompasses the rationale, methodology, physiological and psychological processes as a standard adventure-based programme with one great distinction and that is its culturally appropriate framework. Adventure therapy offers prevention, early intervention and treatment modality for people with behavioural, psychological and psychosocial issues. It can appeal to youth-at-risk who are often less responsive to traditional psychotherapeutic interventions.

Adventure-based Indigenous therapy

The programme uses an eclectic psychotherapeutic framework by an experienced multidisciplinary team, combined with traditional cultural practices and semi-traditional adventure practices that are relevant to the participant community. Evidence of the benefits of an Indigenous-based therapy programme is required for future-based programmes and recommendations to guide clinical practice. This programme was developed following the Camping On Country programme, designed by Uncle Ernie Dingo and Bush Media to take Indigenous men, from rural and remote country towns to return to their traditional Country to provide skills to make Indigenous tools such as boomerangs and didgeridoos. These skills included spear making, three different methods of traditional fishing, harvesting materials for fishing and crafting ornamental traditional pieces. This also provided opportunities to sell these objects, provide financial relief, renew cultural knowledge and provide positive SEWB outcomes. Education was given from health professionals and health checks were also conducted during the 4-day camp. Young men, the community of Mulungu, Mareeba, North Queensland and the local high school and youth agencies, after completion of the inaugural camp, requested Uncle Ernie Dingo to conduct a camp specific for the youth. Due to the high rates of substance misuse, unemployment hopelessness, significant mental illness burden on the community and recent suicides, the community was invested in this novel approach. The community was given feedback from their young people that they would like to have their own camp and talk about their issues. This feedback was facilitated by the strong and active Men’s Health Group at the Mulungu Medical Centre. This ABIT camp was designed to address the high rates of Indigenous youth suicide by utilising a novel approach that combines adventure based therapy (ABT) and Indigenous cultural skills. A yarning circle was created for decision-making, with cultural governance rules applied. Elders shared their personal stories and legends. Traditional fire starting allowed for reflection of SEWB and the sharing of what they were grateful for on that day. On the last night, the young men initiated their own yarning circle and shared what they gained from the camp, recognising that their culture was a part of their own identity and expressing hope to help their younger siblings and families.

Cultural safety

Underpinning the ABIT programme is the concept of cultural safety and the provision of culturally safe environments. This is particularly important for young people who are finding their place—their identity—in the world by connecting to culture and self (Edwards-Groves, 2023). Ensuring the environment is culturally safe means that Indigenous young people feel safe to be themselves, to not be challenged about who they are. The Ramsden model ensures young people feel safe in the environment, and ensures that their experience empowers rather than diminishes their identity, and, most importantly, it is the young people themselves who would decide if they felt culturally safe within the environment (Ramsden, 2002). In practice, the Victorian Aboriginal Child Care Agency (2010) provides a more in-depth perspective, stipulating that, for Aboriginal and Torres Strait Islander young people, cultural safety means upholding their rights to:

• Identify as Aboriginal and Torres Strait Islander without fear of retribution or questioning

• Receive an education that strengthens their culture and identity

• Maintain connection to their land and Country

• Maintain strong kinship ties and social obligations

• Be taught their cultural heritage by their Elders

• Receive information in a culturally sensitive, relevant and accessible manner, and

• Be involved in services that are culturally respectful. (p. 8)

Providing a culturally safe programme was integral to the success of participation of young people and their parent or guardian. Their interactions and engagement indicated they felt culturally safe and supported.

Materials and methods

Objectives

Hypothesis: Adventure-based Indigenous therapy is a culturally safe programme that can improve the mental well-being of Indigenous youth.

Objectives: There is an urgent need for community-driven, Indigenous-led culturally safe mental health and well-being support for young Indigenous peoples. The first programme was delivered in October 2020 in North Queensland. The research proposed will evaluate the ABIT programme using assessment data collected from this programme. The data include assessments taken before, during and after the programme using validated and modified mental health tools and yarning. This is a pilot study that will provide valuable feedback for a novel Indigenous-led SEWB programme, specifically designed for Indigenous young peoples. Our primary aim is to evaluate this novel, culturally safe Indigenous therapy programme. Mental health assessment tools will also be evaluated for their appropriate use in Indigenous young people. This includes the Kimberley Indigenous Cognitive Assessment (KICA) tool as currently it is designed for older Indigenous Australians and there are no cognitive assessment tools for Indigenous youth.

Outcome measures

• Engagement of stakeholders through open communication, representation and advocacy.

• The gathering of information from Indigenous peoples via an Indigenous Knowledge-based technique such as yarning.

• An evaluation with culturally safe recommendations to help guide the best clinical practice.

• Recommendations of the importance of Indigenous-led alternative therapies that are culturally safe for use with Indigenous young people.

• Capacity building with Aboriginal Community Controlled Health.

• Social and emotional well-being questionnaire will incorporate measures of past traumas and cultural beliefs for Aboriginal and Torres Strait Islander peoples, to ensure they are accurate and culturally appropriate. Importantly, a strengths-based approach will be adopted to identify levels of resilience and positive cultural experiences existent in communities to build upon as required.

Study design

Research project setting

In collaboration with the Mareeba State High School and Mulungu Aboriginal Medical Service, Mareeba, North Queensland, 15 young people were selected who were deemed at risk due to their emotional and social burdens. An invitation was extended to the young people and their parents or guardians to attend an information evening on the concept of ABIT and the expected benefits of it. The 13 individuals who accepted the invitation were then arranged for pre-ABIT testing either at their school or if not attending school at their homes or the medical centre. This was conducted within 2 days of the information evening. The Camping on Country team and Bush Media led by Uncle Ernie Dingo assisted with the provision of swags, which is a form of sleeping bag, food and their gourmet and internationally renowned chef and bush skills survivor to assist in the programme. Mareeba State High School and Mulungu provided buses, canoes and six support staff. The support team assisted in the smooth running of the programme and was either employed by Mulungu Aboriginal Medical Service, Mareeba State High School or volunteers that held blue cards for authority to work with children. Four of the support staff were trained in AT and of the four, two of them were trained in CTIAT. The initial camp was held over 4 days in October 2020 in a remote area of Muluridji town, located in Mareeba, North Queensland, ancestral Country.

Methodological approach

An Indigenous psychiatrist ensured appropriate clinical assessments were in place before, during and after the camp. The boys and their families were told that social and well-being data would be collected in the form of clinical assessments and narrative stories. The boys also consented through the community to video recordings. The video recordings included yarning and narrative stories. The data included personal and family health history, mental health conditions and substance abuse history. These data were integral to understand the baseline characteristics of participants and how these might influence their psychological outcomes during the camp. For instance, self-esteem may be influenced by an individual’s history of personal or family aggression or violence, as well as their mental health status, which can be assessed using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). Specifically, the data included personal health, medical history and well-being, family health and well-being and current mental health conditions as per DSM-5: “Personal Substance Abuse History”, “Personal Aggression or Violence History”, “Family Substance Abuse History” and “Family Aggression or Violence History” (American Psychiatric Association, 2013, pp. 834–851). The KICA tool, the Trail Making Test B and Stroop test and in some cases a Montgomery-Asperges Depression Rating Scale and Young Mania Rating Scale (YMRS) were used as clinical assessments in the programme. The YMRS is the most frequently used rating scale to assess manic symptoms, often associated with depression and substance misuse. A modified KICA was utilised to understand the morbidity placed on the individual, to fulfil his family roles and functions. These assessments will be used to evaluate the overall effectiveness of the programme and assess the mental health assessments used for appropriateness for Indigenous youth. We plan to use statistical analyses to explore these relationships, determining how these factors correlate with self-esteem, mood and engagement throughout the camp. In addition, the collected data will allow us to identify any patterns or trends that might predict changes in attention, concentration or other outcomes during the camp experience, providing a comprehensive understanding of how various background factors contribute to participants’ overall well-being.

Indigenous Knowledge methods are utilised throughout this research project to ensure the cultural safety of communities and study participants, for example, yarning. Yarning is considered a valid approach for gathering data from Indigenous communities as it involves an easy-going and unstructured conversation. This conversational style creates a shared experience between the researcher and the participant, enabling them to establish rapport and explore topics of relevance to the research (Kennedy et al., 2022; Lin et al., 2016). The qualitative research component of the project will use yarning for data collection. Another way of passing on Indigenous Knowledges is the use of oral story telling that Aboriginal and Torres Strait Islander peoples use to pass history, cultural knowledges and information to younger generations within Aboriginal and Torres Strait Islander communities (Bonin et al., 2022; McBride et al., 2021). Story telling by the elders on the camp was used as a method to impart knowledge and allow the young people to feel safe.

Aboriginal and Torres Strait Islander peoples govern the collection, ownership and application of all data during this project which ensures the data collected is useful and will benefit young Aboriginal and Torres a Strait Islander peoples. The Australian Institute of Aboriginal and Torres Strait Islander Studies and the National Health and Medical Research Council (NHMRC, 2018) have developed research guidelines specific to research with Aboriginal and Torres Strait Islander peoples. These guidelines ensure researchers do not exploit the young people or their parent or guardian but treat the participants and their communities with integrity and respect. The ethical guidelines worked in parallel with individual community engagement protocols specific to the Mulungu community. To ensure data sovereignty, the Mulungu community are consulted throughout the project from the early development stage to completion.

Study population

Participants were aged between 15 and 23 years of age, identified as being Aboriginal and Torres Strait Islander and consented to participate in the therapy programme. We determined that 13 participants would enable an initial analysis as a pilot study evaluation by community consultation prior to further therapy programme delivery. A Participant Information Sheet detailing the study was provided to the participants and parent or guardian before gaining informed consent. The study was explained by the lead Indigenous clinician at the information session. The study was presented to the school by the lead clinician and Indigenous Health workers. Mareeba State High community education counsellors selected the young men. These young men attended an information session with the lead Indigenous clinician. Participants are able to withdraw their consent at any time throughout the study without providing a reason or experiencing any penalty. All 13 young people who participated in the Adventure Therapy Programme were asked to participate in the study. Ethics was approved via the Queensland University of Technology Human Research Ethics Committee, which met the requirements of the National Statement on Ethical Conduct in Human Research (approval number 4430).

Programme structure

The programme introduced the young people into land and water management. The ecosystem was discussed through cultural storytelling and song lines. This introduces them into Indigenous reclaimed history, storytelling, identity, skill enhancement, horticulture, the basic sciences, astronomy, geography, mathematics, park ranger management, the rites of passage or the transition from boy to man and work ready psychological support. The programme assists the participants to also goal set and manage time. It is envisioned that the programme may be able to incorporate vocational skills in schools. In addition, the programme is also embodied in in situ problem-solving which cannot be afforded in a traditional psychological practice that becomes highly transferable into life practices for the individual. The programme provides cultural resilience against the mainstream perception of a young Indigenous people, plus it allows local cultural investment in its young people as it is dynamic in providing local cultural expertise with elders being integrated into the programme from its initial community planning consultancy.

Processes

The project team plan to evaluate the Adventure Therapy Programme based on demographics and clinical scales and qualitative measures already assessed as part of the programme. We further will assess the appropriateness of the mental health assessment tools used in this therapy programme. The measures in place include a clinical assessment of 50 min with each participant with collection of demographic data. Participants underwent an assessment before, during and post therapy programme to evaluate cognition, attention, concentration and memory, emotional and social well-being and mental health.

Statistical plan

As this is a pilot study, we will infer the size and direction of the therapy effect by using estimation and confidence intervals as the study will be underpowered to interpret p values. The results of the pilot study will inform the design of a larger follow-up study.

Qualitative data collected through yarning will be analysed thematically to provide a rich, detailed and complex account of the data. Thematic analysis will enable the participants’ thoughts, feelings and knowledge of the therapy programme to be included in the evaluation. This will be a crucial step of gathering of information from Indigenous peoples rather than just evaluating pre-existing scales and measures that may not be applicable to Indigenous peoples. Thematic analysis will be performed by: (a)getting an overview of the data which will include reading collected notes, transcribing recordings; (b) collate the data into important phrases and code; (c) convert codes into relevant themes; and (d) write up the outcomes from the analysis.

Quantitative data collected through scales and questionnaires will be analysed using IBM SPSS Statistics. Analysis of Variance with scores added in pre therapy, during therapy and follow-up will be applied to the data. This will also allow covariates to be added to the model. Qualitative data to be analysed include yarning and narrative stories. We are seeking to determine a difference in self-esteem, attention, concentration, mood and engagement. This is measured at commencement at camp and during the camp. These sessions were unstructured, not compulsory and allowed the boys to come around the campfire. Story telling format was culturally appropriate, elders told their stories and the boys told their stories.

Outcome measures

Analysis of the data will measure the direct impact of the therapy programme; how past traumas influence the healing process and identify factors of resilience. Resilience and positive cultural experiences are an essential factor of the analysis as they will inform holistic treatment approaches. We will also validate the modified assessment tools including the KICA. Given that the KICA was originally developed for older Indigenous Australians, its relevance and appropriateness for a younger demographic may not be appropriate. Engaging in a co-design process with Indigenous youth and relevant stakeholders could ensure that the assessment tool is culturally appropriate and resonant with the lived experiences of younger populations. In the evaluation we will identify content, language or constructs that are more aligned with the experiences of older adults and that may not adequately capture the unique challenges or contexts faced by Indigenous youth. An evaluation with culturally appropriate recommendations to help guide the best clinical practice will be produced from the analysis.

Results, outcomes and future plans

All responses will be deidentified and analysed as a whole group rather than individually to protect the identity of the boys. Community members from the Mulungu Aboriginal Medical Service and the boys who participated will be given the opportunity to review the results as a whole and contribute to the publication and communication of results. The whole cohort results will be shared with the parents, boys and community members at an information session. We will be performing mental health and well-being workshops including the benefits of cultural therapy. The community will be involved at all stages of the publication of results and will decide how the results will be disseminated. The Mulungu community will have complete ownership of the results.

Discussion

The over-representation of Indigenous young people in the youth justice system in Australia is considered a national crisis (Australian Institute of Criminology, 2007). Despite being acknowledged as a key issue by various inquiries, little progress has been made in addressing this problem. Indigenous young people make up only 5% of the 10 to 17 age group in Australia, yet they account for 49% of the youth under supervision in both the community and custody (Australian Institute of Criminology, 2007). They are also 23 times more likely than non-Indigenous youth to be in detention (Australian Institute of Criminology, 2007). The historical and ongoing effects of colonisation, broken connections to country and community and intergenerational trauma cannot be underestimated. The Royal Commission into the Protection and Detention of Children in the Northern Territory (2017) highlighted how the destabilisation and history of control of Aboriginal communities have led to chronic disadvantage in physical and mental health, disability, employment, housing and education. The Commission stressed the urgent need to address the impacts of intergenerational disadvantage. However, the complexity of the problem requires long-term solutions to address the entrenched structural issues.

Complex trauma theory is based on feminist theory (Herman, 1992) while also incorporating neuroscience (Corrigan & Hull, 2015) and studies on the embodiment of chronic relational stress (Lynch, 2019). Further, it incorporates intergenerational and cultural perspectives (Atkinson, 2002). The CTIAT framework (Pringle, 2024) enables practitioners to concentrate on the minutia of outdoor practice detail, knowing that the framework is compatible with macro theories and issues. This ABIT programme employs CTIAT with cultural perspectives and knowledge. Much rests on the practitioners’ attunement and identification with those foundational macro issues while also safely leading adventure activities in dynamic and somewhat risky circumstances. Therefore, AT is often conducted by multidisciplinary teams. The CTIAT framework (Pringle et al., 2024) enables each practitioner to apply their skills in conjunction with their peers, even as the ever-changing dynamic situation unfolds.

ABT is an approach to mental health treatment that involves using outdoor activities and physical challenges to promote personal growth and emotional healing. Although ABT has shown great promise in improving the mental well-being of Australian youth (Bowen & Neill, 2013), it also needs to be culturally safe. Indigenous youth often face unique challenges related to cultural identity and historical trauma and, therefore, AT needs to be viewed through an Indigenous lens (Jeffery & Hensey, 2023). Cultural safety must be forefront, to ensure meaning is respectful of and responsive to the cultural values, beliefs and practices of the individuals and communities it serves. This is especially important given the ongoing impacts of colonisation and intergenerational trauma experienced by many Indigenous peoples. Communities have different needs and, therefore, programmes should be created with adaptability.

Culturally safe ABT or ABIT involves creating a welcoming and inclusive environment where participants feel comfortable expressing themselves and engaging in the activities. This may involve incorporating cultural practices and teachings into the therapy, such as traditional ceremonies or storytelling from elders. It may also involve having Indigenous staff members or consultants who can provide cultural guidance and ensure that the therapy is respectful of Indigenous cultures. Evaluation of culturally safe ABIT is also important to ensure that it is effective in improving the SEWB of Indigenous youth. This involves measuring outcomes such as changes in symptoms of anxiety and depression, increases in self-esteem and resilience and improvements in social and interpersonal functioning. It may also involve collecting feedback from participants and their families to ensure that the therapy is meeting their needs and expectations. In addition, outcome measures are often collected using Westernised tools that are not culturally safe or relevant. Therefore, it is important to use Indigenous mental health assessments where possible or evaluate the use of novel tools especially designed for Indigenous youth.

Conclusion

The use of culturally safe and appropriate ABT is essential in improving the SEWB of Indigenous young people. Cultural safety should be inclusive of connection with the land, people and the past. By creating a supportive and culturally responsive environment, ABIT can help youth develop important skills and coping strategies that can improve their overall quality of life. Adventure-based Indigenous therapy can help Indigenous youth build self-esteem, develop resilience, empowerment and self-determination and learn important skills to cope with the challenges they face. These skills can include problem-solving, communication, teamwork and emotional regulation, which can help them avoid negative behaviours and make better choices. By improving mental well-being and promoting positive social interactions, ABIT can help reduce the likelihood of young people engaging in criminal activity or self-harm. In addition, culturally safe AT can help Indigenous young people reconnect with their cultural identity and traditions, which can have a positive impact on their sense of belonging and self-worth. This can be especially important for Indigenous young people who may be experiencing intergenerational trauma related to colonisation and forced assimilation policies. However, it is important to approach this therapy with sensitivity and cultural humility, recognising the unique experiences and perspectives of Indigenous communities and individuals. Adventure-based Indigenous therapy should be part of a larger strategy that includes community involvement, policy changes and ongoing support for Indigenous young people and their families. Further research is required to quantify the healing benefits of cultural revitalisation programmes and traditional practices involved in the transition from boys to men.