Chapter 16 - Services for rural, remote and indigenous Australians
Introduction
16.1
People with mental illness in rural and remote
communities, including many of Australia's
Indigenous people, often are living in communities which offer high levels of
social support. However, they also face great challenges in accessing effective
health care. This was touched on in Chapter 6, which highlighted the low
numbers of mental health professionals in rural and remote Australia,
and this chapter looks at some of the issues in more depth.
16.2
In rural and regional areas stigma can be as socially
isolating as the experience of mental illness itself, as this case study shows:
...wife on farm with depressed and angry husband, combination of
alcohol and isolation fuels deteriorating capacity for communication or
appropriate decision making—husband will not ring anyone, husband will not go
to visit anyone, "they are all useless anyway and what would they know"—
wife doesn’t go out because she’s scared to leave him alone, and she’s embarrassed
by his drinking when out.[1862]
16.3
The tyranny of distance on remote farms and stations,
means being attended in a crisis by rural police officers, with very expansive
geographical and policing responsibilities, and poor knowledge of mental
disorders.[1863] It can also mean long
waits for the flying doctor service, and being sedated, or going out into the
paddock with a gun.
16.4
For Indigenous Australians it can entail being taken
far away from your country among strangers to an alienating clinical
environment or, if you are lucky, connecting with an Indigenous health worker
who can mediate your cultural and clinical needs with sensitivity. This chapter
will assess the service requirements for Indigenous Australians in particular,
after first surveying the situation of people with mental illness in rural and
remote locations generally.
Rural and remote services
16.5
The challenges faced by people with mental illness in
rural and remote areas are well known; they are a subset of those negotiated by
all country people to obtain timely and appropriate health assistance at
distance from hospitals and other specialist services. In a situation where
health services generally, and mental health services in particular, are under
extreme pressure to meet urban population needs, the capacity of state
governments to fund specialist services to people with mental health problems
outside the cities is much diminished:
Rural and remote areas remain under-serviced. Even rural
specific services are generally run from the larger regional centres and
service provision declines as distance from the centre increases. While some of
this is going to be difficult to overcome—population based funding will always
focus on putting workers where there are more people to see—outreach services
need to be specifically funded to reach more isolated populations.[1864]
16.6
The difficulty of attracting medical and health
professionals to rural areas remains a perennial problem:
There is also poorer access to mental health support in rural
and remote areas. It remains difficult to attract and retain health workers in
rural / remote areas, and mental health workers are no exception. Doctor and
psychiatrist to population ratios are low, and there are fewer charity services
to offer support. Members of the [NSW Farmers] Association have suggested that
rural mental health support, from prevention through to crises care, is
“virtually non-existent”.[1865]
16.7
Living in connection with the land can be stressful.
Rural organisations reported that the hardships for country people after long
years of drought compound those arising from the restructuring of the economy
and other social changes.[1866]
Farmers end up in debt and rural support industries are squeezed. The cumulative
effect of this 'financial drought' will last a decade or more, putting some
rural families under unsustainable pressure to keep afloat.[1867]
16.8
While the closeness of rural communities and their
networks of support can assist some who are 'not coping', stigma against mental
illness, underpinned by strong cultural pressures to show independence and
resilience in the face of adversity, means that many of those affected will
suffer silently.[1868] For those with
low prevalence disorders such as schizophrenia or bipolar disorders, which
generally onset during the teens to early adulthood, mental illness in rural
communities can be particularly dispiriting:
In a big city it is easy to hide if you want to. In the country
it is impossible. It is impossible to go the local doctor without the whole
town knowing, so some patients are even more reluctant to seek treatment.
Parents feel isolated as well, and become unable to have social relationships. I
understand from speaking to people in Long Reach that their chances of finding
accommodation or care near there home is very slight.[1869]
16.9
The very public consequences of untreated depression
and anxiety in country areas were widely recorded in the evidence:
unemployment, family breakdown, domestic violence, mysterious accidental deaths
by car or gunshot, homelessness, increases in substance abuse, showdowns with
police and imprisonment.[1870]
16.10
The prevalence of these factors may support speculation
that the incidence of mental illness in rural communities is higher than in
urban ones.[1871] The relationship
between unrelieved stress, lack of knowledge about mental illness, and limited
service options are widely acknowledged catalyst to the high incidence of
suicide among rural males (effectively double that of the rest of the
population)[1872], although this has
not been empirically verified.[1873]
The National Rural Health Alliance (NRHA)
referred to research indicating that it is the lower use of services rather
than the prevalence of mental disorder which contributes to high suicide rates
in rural and regional Australia.[1874] This suggests that service access,
not the incidence of mental illness, is the key issue for country people.
16.11
The isolation of remote communities exacerbates service
delivery problems and decreases the likelihood that problems such as depression
will be diagnosed. A factor contributing to poor health outcomes for rural and
remote Australia
is the higher proportion of Indigenous people living there. While Indigenous
people suffer the same problems as other Australians in rural and isolated
areas, namely reduced access to timely and continuous specialised services, the
invidiousness of their situation is exacerbated by additional historical and
cultural factors.[1875] Indigenous
Australians in cities also have discrete service access problems.[1876] For these reasons, Indigenous
service issues are covered in detail in the next section dedicated to them.
16.12
The two outstanding issues for urgent attention
addressed in this section apply to rural and remote communities generally, and
are:
-
stigma and lack of information; and
-
poor service access, with a particular focus on
GP, carer and community support services.
Getting it out in the open: stigma in rural communities
16.13
Stigma against mental illness, and lack of
willingness to talk about it was identified as a major obstacle to early
intervention, treatment and preventative approaches for people with mental
illness and their families in rural communities. In absence of adequate
services to seek people out, a lack of willingness to seek treatment means no
treatment is received.[1877] For men
and particularly young men, being 'tougher than John Wayne'[1878] reaps the outcomes above; for
women having to be 'the strong one' under conditions of adversity can mean
having 'a lot of responsibility and no control’, with serious psychological
consequences.[1879]
16.14
The National Rural Health Alliance conjectured
that the effects of stigma have broad implications, setting up a vicious circle
between under identification and under
servicing of rural mental health need:
There is a long history of shame and stigma being associated
with mental illness, partly due to people not understanding its nature, causes
and effects. There are lower general levels of education in rural and remote
areas, suggesting that these problems might be worse there than in major
cities. Shame, stigma and associated ignorance may contribute to the relatively
low level of resources devoted to mental health in Australia,
and to the low level of priority that mental health care seems to attract,
including in rural and remote areas.
These attitudinal factors contribute to a reluctance to seek
help. Consequently it is important to implement innovative ways to reach out to
people under stress or facing early stages of mental illness. Barriers to
seeking help are complex and may include issues of confidentiality and trust in
a small community. Also there may be little expectation of help, leading to a
tendency not to seek it.[1880]
16.15
In recognition of these problems, the beyondblue
depression initiative has made rural stigma a target:
One of our great challenges, particularly with men and with
people in rural Australia,
is to have them talk about their illness and seek help and treatment in order
to return to as healthy a condition as possible. We are championing the cause to
have this illness recognised as any other illness. Whether it be AIDS, breast
cancer or a broken arm, an illness is an
illness and it is not a crime to be sick.[1881]
16.16
Rural and regional organisations considered that
campaigns like beyondblue's have positive results in the bush.[1882] Submissions advised that
leadership by a well-known figure like beyondblue Chairman Jeff Kennett had
attracted unprecedented media attention to the issue at the drought summit,
held in Parkes in May 2005. It had also made 'depression' acceptable talk:
—It was good to have
Jeff Kennett there and to be talking so openly about depression—the fact that
it was a figurehead and someone people recognised and that it was okay to talk.
When you go to follow-up meetings, not even on drought, it is interesting to
hear people say, ‘Did you see Jeff Kennett?’ They are actually talking by
accident about depression. The media gave it a great run, and they gave a great
run to the fact that we did not just have a session talking to politicians
about what we needed from drought; we had a session called ‘bugger the drought’—about
how we actually manage the human side of things. The fact that the media picked
it up and ran with it was, I thought, historic, really.[1883]
16.17
The drought summit itself was an important mechanism to
get rural mental health on the agenda, having both a cathartic and therapeutic
effect:
Grown men stood up in
an audience of 2,000 farmers with tears streaming down their face and talked
about how close the end can seem, how desperate farming can be and how bad they
felt that this one drought summit, which was about getting a political result,
was the only reason they had left the farm in three months.[1884]
16.18
The
personal story has great power to dispel prejudice and increase understanding
of mental illnesses in rural situations. The committee heard from a number of individuals
who had dedicated themselves to reducing stigma in rural communities, using
their own experience to bring things out into the open, and to build empathy
and understanding. One approach is through public speaking. Mr Noel
Trevaskis, a Regional Manager Agricultural company and Rotary District
Governor, reported:
Just over twenty years ago I suffered from severe depression and
spent over 5 months in hospital as a result. I found the hardest thing for me
to do was to go back to a small rural area to live with my wife and three small
children because of the stigma that is attached to mental illness.[1885]
16.19
During
the last six years Mr Trevaskis
has spoken of his experiences in a voluntary capacity
to over 15 000 people at over 180 public forums, seminars and conferences
across Australia for organisations such as the DPP and NSW Bar Association, NSW
Farmers, Landcare, farmer drought meetings, Vincent Fairfax Foundation, Women
in Agriculture, NSW Agriculture, Rotary Clubs, Community Mental Health Awareness Forums, Area Health Services,
Road Transport Association and many others.[1886]
16.20
Publishing
your story is another method. HCRRA reports how a young woman with bipolar
disorder decided to 'normalise' her illness after moving to a new town by
raising awareness in rural Australia:
She wrote an article for a newsletter of a prominent women’s
agricultural organisation. As a result many local people who also suffer from
mental illness or who have family members similarly afflicted, have approached
her. She reports the benefits of this ‘outing’ as enormous as a support network
has developed.[1887]
16.21
The need for
broader information campaigns targeted at youth and the aged were noted in
particular.[1888] Rotary clubs,
with government sponsorship and the assistance of the Australian Rotary Health Research
Fund and beyondblue, has the capacity to launch more far reaching education
campaigns.[1889] But the funding of larger campaigns is
beyond most rural organisations, despite the good ideas and rich personal
experience to be drawn on in rural communities. The NSW Farmer's Association
advised that its work on depression, for example, could not be expanded to a
'whole of mental health campaign' without funding assistance.[1890]
16.22
The
care support depression group blueVoices saw education initiatives as integral
to capacity building of rural health services generally, and particularly to community
and outreach services.
16.23
Of particular concern to us is the funding in rural Australia
where services at best are mediocre, and in a number of instances they are
non-existent. Funding should be made available not just for institutional-based
services but a significant portion of funding should be allocated to the
funding of community services, outreach services and educational programs
within local communities. Groups such as Lifeline for example should be funded
significantly to address the mental health activities which they perform.[1891]
16.24
Carer
organisations could play an important role but capacity is largely determined
by available funding:
ARAFMI Hunter offer workshops on stigma, educational materials
on mental illness, group programs on family sensitive practices for mental
health professionals and they distribute information on mental illness
throughout local shopping centres and at community functions. However due to a
lack of funding ARAFMI Hunter can only educate on a small scale and this means
that they cannot greatly impact upon negative attitudes about mental illness as
much as they would like to.[1892]
16.25
New technologies are a very promising means of
increasing knowledge about mental illness in rural communities, proving
immediate access to the web-based information such as that on the beyondblue
website[1893] and the Reach Out! youth
website developed by the Inspire Foundation.[1894]
The potential of the internet to widely disseminate information in rural and
remote communities is entirely dependent however on connection availability and
speed of access, something quite uncertain in many rural communities.[1895] The use of technology as a
clinical tool is discussed below.
Comprehensive country wide services
16.26
As already mentioned, comprehensive data on the true
levels of unmet need for mental health services in rural communities is not
available; there is little epidemiological data to inform local priorities for
mental health interventions, and there are no benchmarks to determine what
constitutes the best mix of services.[1896]
However anecdotal evidence, supported by hard statistics relating to the high
incidence of suicide, of accidental gun and vehicle deaths, and the social
breakdown in small communities across Australia, suggests there is 'something
seriously wrong' in the bush[1897] and
that a holistic response is required.
Service gaps and pressures
16.27
Rural and remote communities reported chronic shortages
of services and health professionals to staff them. They asserted that the
obstacles to comprehensive management and continuous care are obvious once you
step outside of any regional centre: medical health practitioners find
themselves working long hours isolated in small communities with high levels of
need; psychiatrists are in short supply; nurses are underprepared for growing
problems such as dual diagnosis; and community support services to help people
of all ages keep healthy are underdeveloped compared with other areas. Pressure
and isolation encourage high staff turnover, militating against continuity in
care.[1898]
16.28
This results in a situation where services gaps
affecting more well supported communities open out dangerously, as the Burdekin
Report noted:
The irony is that in many of the areas where the need is
greatest the services are fewest. This is particularly the point in small
country communities where mental health services—and certainly mental health
services for children and adolescents—are almost entirely non-existent.[1899]
16.29
The West Australian Child and Adolescent Mental
Health Services Advisory Committee (CAMHSAC) provided insight
into the implications for children and youth in rural and remote communities
and their families in WA:
Models for the funding of adequate rural and remote services
should be based on a population weighted formula as rural and remote area
services frequently perceive that little consideration is given to the needs of
rural and remote services for young people. Tertiary “state-wide” services are
not really accessible to rural and remote families as the programs only cater
for people who live in metropolitan WA or who can readily access the statewide
facilities which are metropolitan Perth based and are run on a Monday to Friday
basis. There is little or no suitable accommodation provided for rural family
members to be near their children who have been admitted to inpatient
facilities. That inpatient beds in the state wide inpatient facilities (PMH and
Bentley hospital) are limited (3 authorised beds at Bentley) resulting in young
people being admitted to adult facilities. Recent funding for more authorised
beds only went to the adult sector. CAMHSAC would like to see appropriate
“youth friendly” beds made available for the 13-25 year olds.[1900]
16.30
The shortage of locally-based psychiatrists and
psychologists in rural and remote areas considerably increases the burden. Only
7.5 per cent of all psychiatrists, for example, are based in rural and remote
areas, while 90 per cent of those practising in non-metropolitan areas are located
in major regional centres.[1901] Consumers
and Carers from the NSW Far South reported:
There is a severe shortage of all mental health professionals
but we particularly feel the shortage of psychiatrists in our area. At present
our sector (including Bega Valley and Eurobodalla Shires which stretch for more
than 250 kms in 6 major centres along the coast and includes about 70 000
people) has funding for 38 hours per week of visiting psychiatrists’ time
(including aged, child and adolescent and adult), however 4 to 5 hours of this
time is taken in travel. There is no
substitute for a psychiatrist living in the area and we believe more could be
done to attract psychiatrists to rural areas. It is essential that funding and
appropriate incentives be provided for a psychiatrist to reside in the area.[1902]
16.31
Lack of appropriate crisis and acute care services in
communities, and of private hospital services, puts unsustainable pressures on
rural public hospitals ill-prepared to meet demand:
There is no crisis service after 10
pm in our area, and people are forced to utilize the emergency
departments at local hospitals without adequate expertise or training for the
nurses who deal with these problems. We have an emergency department Clinical
Nurse Consultant however he must cover 7 hospitals over Monaro, Bega
Valley and Eurobodalla shires. The
shortage of acute care hospital beds in the Southern Area causes many problems.
The only resource for this purpose is at Chisolm Ross Centre at Goulburn, which
is up to 7 hours travel by road for patients and carers, and contains only 15
beds available to people from the old Southern Area. On a per capita basis we
should have 45 acute care beds to cater for this population according to
present policy.[1903]
16.32
On the same theme, NSW Farmers Association
advised:
Wagga base hospital has
around 20 mental health beds available for a catchment of 180,000 people. If
you have that part of the state and draw in 180,000 people, it is a massive
area. Most of those areas do not have access to mental health facilities within
a reasonable distance.[1904]
16.33
These hospitals offer the only possibility for respite
care. This poses particular problems as the care is rarely remedial and is
particularly unsuccessful for Indigenous people.[1905] The inadequate spread of
community-based support services more generally puts immense pressure on
families unlucky enough to live in or near towns without any support
systems:
In our rural town...There is simply no accommodation service and
the rehabilitation service comprised only irregular visits by a case worker.
This is why we have had to relocate our son (after his second
psychosis) to another town so we could get him admitted to a program which does
offer rehabilitation and accommodation services. And despite assurances from
our local Community Health and the Area Health Service, our experience was that
our son could not get an admission to this other service unless he had an
address in this other town. So we had to tear around and find him a flat to
live in this other town to facilitate this admission. He lived here for a
number of months while still acutely unwell, until he was deemed to be “a
local”, was assessed and then he had to wait for a place at the accommodation
facility to become available.[1906]
16.34
Community 'drop in' centres or other social support
networks reduce the burden of stigma and make people feel more positive and
less isolated, but are not available in
rural areas.[1907] The lack of
services to treat the growing number of people with dual diagnosis in rural
areas[1908] is compounded by a total
absence of support services common in the city:
I live thirty minutes away form Albury/Wodonga and find
travelling major cost...and time to get the support and help I need to maintain
some sort of normality in my life...I wish that a group could be set up for
people like me...I am amazed to find many other people suffering from mental
illness and substance abuse.[1909]
16.35
The general practitioner is usually the first person to
diagnosis a mental illness in a rural setting.[1910] However rural and remote
communities can struggle to find and retain sufficient GPs for their local
population. The committee met doctors and community members in Port Hedland.
Members were struck by their dedication, but also by the heavy workload that
came from having fewer doctors in the practices there than were needed.
16.36
Despite the promise of the Better Outcomes initiative,
rural and remote GPs are rarely able to get away to do the prerequisite
training to participate. SA Divisions of General Practices advised:
The more remote Divisions report considerable difficulty
accessing the required training for their GPs to participate in the BOiMHC [Better
Outcomes] scheme, and difficulty attracting appropriately qualified and
experienced personnel. Training of GPs to do counselling themselves (Level 2
under BOiMHC) is likewise difficult as it requires the GP to do 20 hours of
training – not available in the country thereby necessitating the GP to leave
their practice unattended for a number of days. With the lack of available
locum coverage to backfill, and rural doctors required to provide after-hours
emergency care, this may leave entire towns and regions without any medical
care.[1911]
16.37
Consequent to the lack of specialist support, attendant
work pressures and problems of distance GPs tend to follow a medical model of
treatment for conditions such as depression. Submitters identified a number of
problems with this approach. Changes in medication can have unpredictable
outcomes, such as unforseen medical or psychological affects.[1912] The availability of guns at home
can increase the risk of suicide or violence.[1913] Referral to a mental health
caseworker brings other attendant risks given the long waiting lists.[1914]
16.38
In remote locations this combination of factors can be
even more risky. There may be access to a GP or specialist on a fly-in fly-out
basis but follow up by case workers and social workers and maintenance programs
are not usually accessible.[1915]
Further, the transport and treatment of individuals in acute states can be
complicated by different mental health regulations, for example, in the Northern
Territory:
People suffering psychotic episodes in a remote area, are
required to be sedated to be evacuated by air. To travel by aircraft, these
people require sedation. From the time they are sedated, travel to a health
facility and recover from their sedation, the period of time a person can be
kept against their will has expired. This means a seriously ill person can
leave a health care facility without having received any treatment for their
mental condition.[1916]
16.39
Even if relocation of people for treatment is feasible,
it can also be disruptive, and work against recovery. At Port Hedland the committee
heard how specialist treatment could involve relocation thousands of kilometres
to Perth. Such distances make it
difficult for any family to maintain contact and support; for Indigenous
families and consumers it can be particularly traumatic. Service provision in
places like the Pilbara/ Kimberley
region can also bring jurisdictional issues into focus. It would frequently
make more social and economic sense for consumers to get specialised care in Darwin
rather than Perth, but crossing
jurisdictional boundaries can make this difficult or impossible.
16.40
In rural and remote absence of adequate follow-up and
maintenance programs increases the likelihood of relapse. Carers may be
isolated with very unstable family members and have to travel long distances to
gain treatment and support. A focus on developing more adequate relapse
prevention and respite support for people in rural areas is necessary, and may
include ensuring that carers are aware of available pension support and travel
assistance allowances.[1917]
Information and training for police, who attend and manage crisis situations
without specialist advice across vast geographical areas is also essential.[1918] Mandatory mental health first aid
training or programs such as Living Works which have a 'train the trainer'
aspect were recommended to dispel misunderstandings and enhance skills among
rural police, ambulance drivers and crisis carers.[1919]
Technology—clinical services and counselling
16.41
Technological developments including teleconferencing
and video conferencing were cited as having significant potential to improve
services to rural and remote communities. Telepsychiatry is one of the newer
technologies which is being used to deliver better mental health care services
to rural and remote communities:[1920]
In rural and remote mental health services a programs approach
has been adopted with the CAMHs program being run within a generic mental
health service usually managed by adult mental health team
leaders/mangers/psychiatrists with only CAMHS specialists available by video
conference only. This is likely to result in a broad range in the capacity of
services to provide specialist CAMHS clinical services particularly in rural
and remote areas.[1921]
16.42
Ms Jenine Bailey, an Indigenous researcher who provides
mental health counselling through the correctional centre at Townsville,
reported the usefulness of teleconferencing to establish continuing treatment
plans and to make important personal introductions to released Indigenous
people to health workers back in their home country:
I did teleconferences to introduce the people. I actually
referred them to services or workers to meet them once they got there, to
basically start that. Before that, you would discuss and co-case what I had
done with the person within the facility and, once they were released, in the
community. You put the strategies in place before they get out. You have a fair
idea of their release date, so you make sure that things are in place so the
person is not left out in the cold and lost and therefore may get up to
mischief again.[1922]
16.43
Access to training and referral advice for health
professionals in remote and regional Australia
is one important benefit provided by internet access. The Northern Territory
Government reported that its on-line mental health program site is a training
reference and resource tool to clinicians.[1923] The development of cognitive behavioural
therapy sites, as a subset of e-mental health and information services
discussed above, also has great potential for rural and remote consumers.
BlueVoices commented:
There are a number of cognitive behaviour therapy programs
online to assist people, and whilst these should not be seen as being able to
take the place of direct service intervention in rural or remote communities,
they can offer a service where none currently exists. Web-based services can
also be used to offer education and we cite the beyondblue website as well as
our virtual network as examples of how technology can be used to increase
education and support for persons in rural and remote communities as well as
urban communities.[1924]
16.44
While the relative benefits of on-line services and
other counselling approaches have not yet been evaluated, there are positive
cost and service efficiencies:
Since 1997, Australia
has been leading the world in the delivery of e-mental health services;
however, no consistent investment has been made by Government in these emerging
technologies, and little research has been done into the comparative benefits
of web-based service delivery over phone-based and face-to-face service
delivery. The research that has been undertaken
indicates that web-based services that provide mental health information and
support can significantly improve mental health outcomes. New developments in
technology mean that cognitive behavioural therapies can be adapted into an
online environment and be delivered without a counsellor, while still providing
the same mental health outcomes at a fraction of the cost.[1925]
16.45
The clear success of online services like that provided
by depressioNet, which runs a peer-based 24 hour online information,
counselling and chatroom facility for depression sufferers,[1926] demonstrates the need for these
types of services, and argues for more reliable and efficient online capacity
in country areas.[1927]
16.46
The Inspire Foundation's Reach Out! for example, fills
a niche for rural youth, not covered by the telephone counselling service Kids
Help Line, which assists the under 18 years, or Lifeline, which receives only
10 per cent of calls from the 14 to 18 age group. Inspire reports that, in the
financial year ending 2005, there were 760 000 individual visits to Reach Out!
The service currently attracts 75 000 plus individual visits each month.[1928]
16.47
At the same time, online services must complement not
replace an early human response in a crisis. This advocates for increased
mental health and crisis support services in the bush, including support for
telephone counselling services like the Kids Help Line which focuses on 8 to 18
year olds in rural and regional Australia,
on the premise that these kids are at greater risk of mental illness than those
living in cities.[1929]
A 'population health' response
16.48
A piecemeal approach to mental health reform will not,
it was argued, be sufficient to address the considerable obstacles imposed by
distance and culture in rural and remote communities. Instead, a holistic model
of service is required. In this regard, rural stakeholders expressed
disappointment that the National Mental Health
Plan 2003-2008 has failed to acknowledge the specific needs of rural, regional
and remote communities. Moreover, as the National Rural Health Alliance
(NRHA) noted, two of the Plan's most relevant priorities—'increasing service
responsiveness' and 'strengthening [service] quality'—remain distant goals for
most rural communities, given chronic service and staff shortages.[1930]
16.49
Drawing on the template of its Healthy Horizons Outlook 2003-07 policy document, the NRHA proposed
that the Government immediately implement a 'population health' approach to
rural and remote menta health.[1931] This
holistic model aims to breakdown intersectoral service barriers and build
partnerships between social, community and health services. Based on the
Department of Health and Ageing's National
Action Plan for Promotion and Prevention and Early Intervention for Mental Health, the model has an early intervention
emphasis, but assesses problems across seven priority age groups. This program
of attack necessarily relies on sustained and judicially allocated funding to
achieve 'appropriate treatment and continuing care services, and [a] comprehensive
approach to prevention'.[1932]
16.50
Project-based funding was heavily criticised by rural
commentators as being particularly onerous for overburdened rural health
professionals. The HCRRA noted that staff burnout is a serious issue in the
country because of the hours, large caseload and geographical area to be
covered. 'Application burnout' becomes endemic as these overworked rural staff struggle
to retain project-based grants'.[1933]
Non health trained staff who play an important role as mental health lightening
rods in rural communities, also fall prey to the problem. One important player
during the drought years has been the Rural Financial Counsellor, as the NSW
Farmers Association advised:
The Rural Financial Counsellors...are often
the first to receive a farmer in despair. Whilst these counsellors provide
financial assistance, they are skilled in identifying farmers with emotional
need and referring them on. The services these counsellors provide are
absolutely essential for the wellbeing of farmers, particularly during times of
hardship such as drought, something their long waitlists attest to.
Unfortunately the Rural Financial Counsellors continue to face uncertainty in
their positions as they must regularly reapply for funding through an arduous
administration process.[1934]
16.51
The Australian Infant, Child, Adolescent and Family Mental
Health Association (AICAFMHA) and others that argued that the
many proven 'innovative' approaches to service delivery and training in rural
and remote areas now deserve Government's commitment.[1935] To achieve this result, and support the
revitalisation of rural communities, the NRHA advocated that funding to support
continuous care should be based on the population health calculation, under
which rural communities at 30 per cent of the population, should receive
proportionate health budget increases. Moreover this funding should be
recurrent and subject to monitoring and reporting requirements. This should be
achieved as part of an increase in overall health funding to 12 per cent of
national expenditure.[1936]
Indigenous Australians
16.52
During this inquiry, health outcomes for Indigenous
Australians were described as 'completely inadequate'.[1937] The National Rural Health Alliance
stated:
The appalling health of Aboriginal Peoples and Torres Strait
Islanders is a major contributor to the overall poorer health of people living
in rural and remote communities.
This group must be given priority in improving mental health
outcomes.[1938]
16.53
The
Royal Australian and New Zealand Congress of Psychiatrists (RANZCP)[1939] and the Royal Australian College of General Practitioners (RACGP) have both
issued clear position statements on Indigenous health. The RACGP submission
stated:
The RACGP has a clear
position statement on Aboriginal and Torres Strait Islander health that
recognises improving the health of Aboriginal and Torres Strait Islander people
is one of Australia’s highest health priorities.[1940]
16.54
Data set out in evidence before the committee
establishes the uncontrovertible truth that Indigenous Australians have neither
the life expectancy, the emotional or psychological security, nor level of
material comfort other Australians enjoy:
-
the perinatal mortality rate for babies born to
Indigenous women is twice as high as that for babies born to non-Indigenous
women;[1941]
-
Indigenous Australians have at birth a life expectancy
of twenty years less than other
Australians;[1942]
-
Indigenous people have much higher rates of
premature death due to external causes, 16 per cent of all deaths compared with
6 per cent for other Australians. Death due to deliberate self harm was 33 per
cent for men and 15 per cent for women;[1943]
-
Indigenous people have a significantly higher
risk of experiencing major life stressors than other Australians, which affects
their mental health and general wellbeing. Indigenous children are at higher
risk of clinically significant emotional or behavioural difficulties; at 24 per
cent compared with an equivalent figure of 15 per cent in the general
population;[1944]
-
Indigenous
people are twice as likely to die of alcohol attributable diseases, despite the
fact that alcohol intake is equivalent to that of the general population;[1945]
-
Indigenous youth self-harm and suicide rates are
much higher compared with other Australian youth. Of Indigenous youth 12 to 24
years, 31.1 per cent per 100 000 intentionally self harmed, compared with 6.4 per
cent in a 100 000 of other Australian youth.[1946] More than one in six, 16 per cent, of
Indigenous young people aged 12–17 years had seriously considered ending their
own life in the 12 months before the survey; of these, 39 per cent had attempted
suicide.[1947]
-
Indigenous Australians have higher rates of
unemployment, poorer educational outcomes and lower rates of home ownership;[1948] and
-
at June 2002, Indigenous people were 11 times
more likely than non-Indigenous people
to be in gaol.[1949]
16.55
The marginalisation of people
with mental illness is therefore compounded in the lived experiences of
Indigenous peoples, making them potentially, as the United Nations recently
suggested, the most disadvantaged community in the world today.[1950]
Policy responses
16.56
With these circumstances unimproved after many years of
various policy approaches, the Government has recognised that overturning poor
Indigenous health outcomes requires attention to the full spectrum of Indigenous
life experience. This was first acknowledged in The National Aboriginal Health
Strategy (1989), which defines Indigenous health as:
Not just the physical well-being of the individual but the
social, emotional, and cultural well-being of the whole community. This is a
whole-of-life view and it also includes the cyclical concept of
life-death-life.[1951]
16.57
The Office of Aboriginal and Torres Strait Islander
Health (OATSIH) reports further advances on this holistic agenda, with the
development of the National Strategic Framework for Aboriginal and Torres
Strait Islander Peoples Social and Emotional Wellbeing and Mental
Health 2004–2009 (the SEWB Framework). OATSIH advised:
The SEWB Framework aims to broadly address the social and
emotional wellbeing and mental health needs of Aboriginal and Torres Strait
Islander people. The document acknowledges that a range of government policies
and practices has impacted on the social and emotional wellbeing of all
Aboriginal and Torres Strait Islander peoples, including the ‘terra nullius’
policy, protection and assimilation policies, as well as the removal of
children from their families. The document aims to provide a framework for
action by all governments and communities to improve Social and Emotional
Wellbeing in Aboriginal and Torres Strait Islander communities over the next
five years.[1952]
16.58
However, despite being due for release in March 2005,
OATSIH reports that arrangements are just now being made for the publication
and dissemination of the Framework.[1953]
The tendency to delay the rollout and implementation of important components of
Indigenous mental health policy—which have been agreed to and supported by
Aboriginal people—was strongly criticised in submissions.[1954] The Aboriginal Health and Medical
Research Council of New South Wales stated:
The National Aboriginal Health Strategy (1989) is the foundation
national document for policy, resource allocation and service delivery to
Aboriginal people in health and health related matters and it has to be noted
that many of the recommendations defined in that document are yet to be
implemented. The Ways Forward and Bringing Them Home Reports documented and
validated issues that Aboriginal people have been constantly raising, and the
needs and strategies addressed in these reports continue to be relevant.[1955]
16.59
The consequence, as National Rural Health Alliance
observed, is that Indigenous health needs remain largely unaddressed:
The National Aboriginal Mental Health
Policy and Plan, published in 1995, canvasses extensively issues relating to
mental health for this vulnerable group and included strategies and goals.
Despite this the mental health of Australia’s
Indigenous Peoples remains poor.[1956]
16.60
With the policy framework further refined to better
acknowledge the extent of damage inflicted by the history of colonisation and
the past policies of family separation and assimilation, submitters exhorted
the committee to urge adherence to key policy commitments made in the
framework, principally that services be:
-
Culturally appropriate—responsive to the
diversity of Indigenous peoples and their beliefs, and delivered by trained
Indigenous health workers of the appropriate sex; and
-
Community-controlled health services—funded and
operated by communities.
Culturally appropriate services
16.61
Indigenous people with mental illness experience extremes
of social and psychological divorcement. Alienated from their families and
country of origin, and hence from their identity, many are out of touch with
traditional networks of help. This has important implications for the nature of
services to be provided:
Primary prevention requires a greater focus on the social
determinates of mental illness amongst Aboriginal people. This includes the
need to recognise and address the historical trauma created by the experience
of colonisation and dispossession as well as the specific trauma of the Stolen
Generations. It has been suggested that the extent of this trauma is such that
many Aboriginal people are suffering from symptoms suggestive of Post Traumatic
Stress Disorder. This has been more extensively described for Aboriginal people
in Canada but
is almost certainly true in Australia
as well.[1957]
16.62
As indicated here, research on the extent of this
damage and on the most effective means of addressing Indigenous mental health
needs is underdeveloped in Australia.[1958] For example, diagnostic tools for
assessment of mental illness among indigenous are underdeveloped.[1959] The
Human Rights and Equal Opportunity Commission noted that while the Western
Australian Aboriginal Child Health Survey (WAACHS), quoted above and below, provides
a watershed: 'A first step in any address to Indigenous mental health is to address
the paucity of data collections in this area'.[1960]
16.63
Notwithstanding this, the major contention in
the evidence was that the situation has not improved because the long espoused
commitment to deliver culturally appropriate services has not received full
government support.[1961] In this regard, Indigenous researcher Ms
Jenine Bailey, a Jagara woman from Brisbane now resident in Townsville,
told the committee that the key message to mainstream health providers
is: 'You are not listening to me;
Aboriginal mental health is different'.[1962]
She explained:
As an Aboriginal mental health worker, I have experienced
first-hand the frustrations related to access and/or deliver of culturally
appropriate mental health services to the community, when continually
confronted by obstacles, gaps or lack of capacity in service delivery that
hinder my work practice. These obstacles include lack of funding and/or
inappropriate recognition for Aboriginal mental health, inadequate support from
mainstream mental health workers and services, the stigmas associated with
Aboriginal mental health, misunderstanding that Aboriginal mental health and
the concept of health is different to western concepts of health and therefore there
are different needs, and no recognition for cultural mental health differences
between different Aboriginal communities.[1963]
16.64
One
myth exploded by the WAACHS findings was that living in rural and remote
communities confers poorer health outcomes on Indigenous people. Submissions
referred to WAACHS data indicating
that the environmental safety and health (ESH) of Indigenous children actually
improved with isolation, that is, in remote communities. Children living in Perth had significantly poorer (five times worse)
ESH than those living in very remote communities.[1964]
16.65
While
Indigenous people are the largest group as a proportion of remote and rural
populations and experience problems consequent to that isolation.[1965] The important realisation arising
from these findings is that culturally appropriate assistance to urban
Indigenous people is urgently needed.[1966]
It was suggested that urban-based services must recognise the psychological
effects of cultural dislocation, such as through the stolen generations policy,[1967] and still be responsive to the
different Indigenous cultural expectations, linking back to the particular
beliefs of the client's country of origin:
There are those complexities in our culture. It depends where
that person is from. The same applies to a woman speaking with a male
psychiatrist; she would not feel right. There were times when I had the whole
extended family, including an aunty, an uncle and cousins, because they take it
all on. It is not just a one on one with the psychiatrist, it is a very big
family group, and they will have a family meeting about it. It is just that
understanding that it is just not one person going through the mental illness;
it actually involves the family, and therefore it ripples out into the community.
It just depends on the person who walks through the door. You must be aware of
that. Torres Strait Islanders are different from Aboriginals, and it depends
where the community is from. Just because they are an Aboriginal does not mean
that way of treating and therapy, or applying strategies for care or whatever,
will work for them as it does for somebody in Alice Springs,
for instance.[1968]
16.66
Because the Indigenous concept of health is quite
different to European understandings, the cultural nuances of diagnosis are
complex.[1969] Self harming can be
part of ritual observances for mourning, or an expression of depression or
other grief;[1970] hearing voices can
be seen as communication with ancestors, a men's business matter. Trained
Indigenous workers of the right sex with appropriate cultural knowledge are
essential to assess, interpret and assist. Mainstream psychiatrists in urban
settings have little capacity to do this.[1971]
At the same time shortages of psychiatrist in rural settings ensure that access
to these services is even more limited for remote Indigenous communities.[1972] The Central Australian Congress
provided its template for more responsive care:
There needs to be greater attention given to the language and
cross cultural barriers that arise when psychiatrists are employed who have
English as a second language...there is also a need to address the shortage in
mental health nurses working in remote areas. Acute care facilities need to
have access to interpreters and Aboriginal liaison officers who can ensure that
there is good communication between inpatients and there families. There also
needs to be close liaison with the primary health care sector and many patients
should have pre-discharge care plans developed with their primary health care
provider to ensure that follow up is collaboratively planned. Congress has re-developed
the job description of our mental health worker position to make this the prime
focus of his job and we hope this will lead to better coordination of care and follow
up of our patients who are in and out of ward.[1973]
16.67
Indigenous health workers carry much of the load in
building bridges in communities, although this in currently not recognised.
Service providers argued that the key to improving Indigenous health outcomes
relies on handing over control for design and delivery of these services to
those who know best:
...we need to recognise the clinical and
cultural capacity of Indigenous mental health workers within [the] mainstream
to direct and guide service delivery for Indigenous users.[1974]
16.68
Mr Jonathan
Link is of Australian Aboriginal and Maori descent[1975] with health program
qualifications. He is a Community Liaison and Development Officer with the Royal
Flying Doctor Service, working in remote areas of the northern Cape York where services are spread thin.[1976] His experience resonates the
important role of Indigenous health workers in bridge building in these
communities:
I have been travelling
to these communities for two years now and through meeting people in their
homes, at the clinic, whatever the organisation, we try to express that
individuals need to take control of their community, especially in their homes.
For example, if I was going to your place, you would not expect me to come and
invade your home. It is the same principle of us coming into a community and
trying to tell them how to be. My role is to give them an opportunity to see
that there is support. You are not going to always have the answer within
communities, especially around raising awareness issues. Mental health is a
stigma in Indigenous communities, so my role is to just be a person who will
listen. That is a very important factor there. The communities tend to be
reactive rather than proactive; if there is an issue there they tend to act on
it straight away without actually coming together as a group. Listening to
them, showing that you are transparent and not promising things that you cannot
deliver are important. I believe I have made inroads there. [1977]
16.69
Mr Link considers that lack of services and
employment are major catalysts to mental illness in Indigenous communities,
particularity among men and boys.[1978]
He advocated a two-pronged approach: development of social and cultural infrastructure;
and attention to the training and working conditions of local Indigenous health
workers:
I would like to see cultural schools. I would like to see
drop-in centres for youth, elders and people in the middle age groups. I would
like to see traditional healers and elders having a bit more input into the way
people feel. There is a big gap in the way our people interact with each other.
Also I would like to see more money for health workers and a health worker
exchange program. When nurses have holidays, there is always a replacement, but
there is nothing there for Indigenous health workers. If you could implement
and fund that particular initiative, that would be great.[1979]
16.70
The depression initiative, beyondblue endorsed the view that social mentoring activities have
potential to address mental health issues in Indigenous communities. Mr
Kennett referred to the copycat suicides of
a dozen young Aboriginal men Swan Hill in Victoria
as an indicator of urgent unmet need:[1980]
...the Aboriginal
community does respond very well to peer influences and particularly to
footballers. Most Aboriginal communities are involved in football. We are
actually looking at the moment at incorporating one or two of these people,
properly trained—and there are a number who have suffered depression but who
are very good communicators—to try to lift self-respect amongst some of the communities.
The important thing is not to go in and conduct a program and then leave them.
We have to have a method of going back every three months, six months and 12
months. That is fairly costly, but it has to be done. You cannot just go in
once and think that you have educated someone. [1981]
16.71
Submissions confirmed that the difficulty of obtaining
and retaining skilled locally-based Indigenous health workers, particularly
male workers, in all areas is a major obstacle to delivery of continuous culturally
appropriate mental health care.[1982]
Studies show that Indigenous people are discouraged by hierarchal and 'silo'
structures in the medical health industry and have a lack confidence in
negotiating the education process,[1983]
leading to low rates of retention in both instances.[1984]
16.72
Indigenous only education venues have proven successful
in providing the type of collaborative culturally affirming learning
environments essential to achieve positive outcomes for Indigenous people.[1985] Mr Link achieved his
qualifications at the Bachelor Institute
Indigenous College
which he suggested should have support.[1986]
Ms Leanne Knowles, Manager, Social Health Unit, WuChopperen Health Service proposed
the introduction of scholarships for Indigenous health professionals, and incorporation
of Indigenous Health curriculum in mainstream courses would assist.[1987]
16.73
A ray of hope in both respects is the Djirruwang
Program at Charles Sturt
University which offers a Bachelor
of Health Science (Mental Health) Degree to
Aboriginal and Torres Strait Islander people. The Program adheres to the National Practice Standards for the Mental Health Workforce 2002, to ensure graduates are
imbued with the skills and ethical values of the profession while maintaining
'a deep sense of cultural integrity'.[1988]
The submission recommended the Djirruwang Program
Clinical Handbook and Course Competencies be adopted as the standard for
national accreditation in Indigenous mental health practice to promote
culturally supportive practices in the mainstream health system.[1989]
16.74
The inadequacy of available treatment for people with
dual diagnosis is a matter of national concern addressed elsewhere in the
report. The lack of specialised services to assist Indigenous communities to
deal with co-occurring disorders was raised in submissions as a cause for
shame. The Probation and Community Corrections Officers’ Association
Incorporated (PACCOA) advised:
A PACCOA member recently reported that there is a significant
problem in Aboriginal communities concerning the issue of both mental illness
and “undiagnosed” mental illness due to inadequate resources in these communities.
These are often people being treated for addictions, and fall under the dual
diagnosis umbrella. Often these communities do not have basic drug and alcohol
services. At one Probation and Parole District Office, there are over 30
offenders with significant drug and alcohol issues, but no counsellor. Even
though every effort is made to fill the gap by bringing in the services from
outside the communities, wherever possible, the responsibility falls to health
services. It has been recommended that, given there is a dual diagnosis
treatment trial under way, such trials should be extended to poorly resourced
Aboriginal communities where the treatment is so urgently needed.[1990]
16.75
The effect on Indigenous children and young
people has not been fully counted in the equation of need, having been limited
to addressing single issues such as the petrol sniffing epidemic:[1991]
Services for Aboriginal Australians continue to be acutely under
funded, struggling to meet basic needs. Breakdown of traditional family
structures and the loss of virtually entire generations due to substance abuse
means parenting skills have been lost putting Aboriginal children in a
situation of crisis. Community resources are reduced, leaving just the old
struggling to care for the young as they handle their own ill health and
poverty related issues. Mental health programs need to be integrated and
integral to the overall health, social and emotional wellbeing programs that
need to be funded for Aboriginal people, implemented in a culturally
appropriate and socially acceptable manner.[1992]
Community-controlled services
16.76
Building self esteem and a sense of empowerment is an
important element in recovery-based models for care of all people with mental
illness, and is particularly important for Indigenous people. This fact was
recognised in the National Aboriginal
Health Strategy:
The greater the degree of control a
person has over their life and the greater the degree they feel they can
participate in (influence) the way their social environment operates, the
better their physical and mental health will be. [1993]
16.77
It was cogently argued in the evidence that the best
way to manage and ameliorate the levels of distress in Indigenous communities,
and so to achieve progress with mental health and social outcomes, is to give
these communities the power to determine the nature, scope and presentation of
services to their own people:
In certain areas
Aboriginal mental health workers are placed in mainstream health services (or
an Aboriginal staff member is designated that role), giving rise to problems of
access and appropriateness when Aboriginal people won't utilise services for
cultural and historical reasons. NCOSS strongly supports the placement of
Aboriginal mental health workers in Aboriginal community-controlled
organisations, from where they would work in conjunction with mainstream
services to provide mental health services to the Aboriginal community. This
would be consistent with the National Aboriginal Health Strategy, which has
been agreed to by the NSW government and recognises that Aboriginal community
controlled organisations are the best means for delivering health services to
Aboriginal communities.[1994]
16.78
The committee received a number of reports of community
controlled models and partnerships which are achieving results:
One such program is the Aboriginal Primary Health Care Access
Program (APHCAP) which has considerable acceptance within the communities in
regional SA and actively engages with Divisions of General Practice, is setting
up Aboriginal controlled health centres on a “one stop” model. Workforce
development for Aboriginal health workers in mental health is much needed, as
well as these workers being able to easily access specialist support.[1995]
16.79
However, there were very grave concerns that the
funding needed for community controlled Indigenous health services, despite the
rhetoric, is not ending up in Aboriginal hands. The experiences of the Central
Aboriginal Congress are indicative:
...in 1997 when Alice
Springs began experiencing a major upsurge in the rate of youth suicides Congress
called a meeting of all Aboriginal organisations in Alice
Springs and established an Aboriginal youth committee to discuss the problem
and help to develop potential solutions. In spite of this process Congress was
unable to access any of the national youth suicide prevention funds to
establish programs in accordance with community proposals because all of this
money had been given to the states and territories.[1996]
16.80
The Congress was later informed that all the youth
suicide prevention money had been given to the Northern Territory Government
for redistribution to community organisations, such as the Congress. The funds,
however, were transferred to a non-Aboriginal mental health NGO. The Congress
commented:
...given that the principal need is in the Aboriginal community we
do not think this is the best option. Aboriginal community controlled
organisations have the best chance of providing such programs in a manner which
will meet the needs of their communities and achieve health outcomes. Because
of the difficulties that Aboriginal people are experiencing in accessing funding
for social and emotional well being services and programs OATSIH are having to
primarily use their PHC resources to fund the delivery of social and emotional
well being services within Aboriginal community controlled PHC services. Such
services should be funded with mainstream Mental Health specific funds.[1997]
16.81
Congress maintains that Indigenous-controlled community
services are best placed to build capacity to deliver targeted and culturally
appropriate services to youth and remote communities.[1998] Denial of direct funding to
Indigenous organisations is contrary to the principles of community ownership
and control espoused as Australian Government policy, not withstanding the
insult to the Indigenous committee fora convened especially to consult over
suicide prevention. The draining of dedicated OATSIH funds to support
identified national mental health
priorities, seems ill considered given the high level of complex unmet need
among Indigenous communities.[1999]
16.82
Government evaluations have shown that only 38 per cent
of Aboriginal Community-controlled organisations have a dedicated mental health
or social and well being worker.[2000]
To foster genuine and effective local community-based mental health services
around the country, submissions asked that the Government honour both the
letter and the spirit of its commitments. Aboriginal Health and Medical Health
Services advised that national leaders must:
-
require all stakeholders to comply with existing
Aboriginal health agreements, policies and processes at state, regional and
local level;
-
support those programs and providers currently
providing services which the Aboriginal community value and utilise;
-
enhance culturally appropriate services
targeting Aboriginal children and adolescents, either directly or indirectly;
-
support dedicated Aboriginal Health funding
being directed to Aboriginal community health services to administer the development, implementation and
evaluation of programs;
-
secure effective implementation of state and
local policy to Aboriginal Mental Health Workers in the public, private and
Aboriginal community controlled health sectors; and
-
promote effective coordination and support of
local mental health services.[2001]
16.83
To be effective, these core recommendations must be
underpinned by a full commitment at federal level, in terms of recurrent
funding, policy development and support for implementation of Indigenous
emotional and wellbeing program. Submitters argued that this must be more than
just rhetoric, backed up by the politics of mutual obligation. It must be based
on genuine respect for what traditional cultures offer, and recognition that
self determination of Indigenous people over conditions of life in all states
and territories will be the foundation of real progress in Indigenous health.
Other groups: Gay, Lesbian, Bisexual and Transgender
16.84
The AIDS Council of NSW (ACON) told the committee that
mental health problems are more common among gay, lesbian, bi-sexual and
transgender (GLBT) people than among the population in general.[2002] This relationship is related to
society's response to homosexual and transgender people, many of whom
experience discrimination and stigmatisation.[2003]
16.85
Discrimination impacts not only on the mental wellbeing
of GLBT people, but on their ability to access mental health services. Further,
multiple discrimination, on the basis of both mental illness and sexuality, can
seriously affect GLBT people's access to wider support services, such as
housing, employment, law enforcement and general health services.[2004] Training is required to ensure
appropriate service delivery:
It is important that all state and national strategies and policies
recognize this and work to eliminate homophobia and discrimination on the basis
of sexuality and gender identity.[2005]
16.86
ACON suggested that community-based organisations are
well positioned to provide culturally appropriate health services and support
for GLBT, but note that funding is currently limited.[2006]
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