A Systematic Review: Non‐Suicidal Self‐injury in Australia and New Zealand's Indigenous Populations

Objective

To undertake a systematic review of non‐suicidal self‐injury (NSSI) prevalence, patterns, functions, and behavioural correlates for the Indigenous populations of Australia (Aboriginal and Torres Strait Islanders) and New Zealand (NZ; Maori).

Method

We searched the following electronic databases: PubMed, MedLine, Scopus, Web of Science, ScienceDirect, PsycInfo, and PsycArticles, CINAHL, and the Informit Health and Indigenous Peoples collections. Studies were included for review if they were published within the last 25 years and reported on NSSI in Australia and NZ's Indigenous populations.

Results

Seven studies were included, six of which came from Australia. The prevalence of NSSI in Australia ranged from 0.9% up to 22.50%; statistics varied by the different samples, types of prevalence, and relationship to alcohol. Several studies found that Aboriginal and Torres Strait Islander peoples had higher rates of NSSI than other Australians, but that this was not significantly higher. Two studies indicated that NSSI was linked to alcohol use, incarceration, and a younger age. The one NZ study was of injury and not specifically NSSI.

Conclusions

Findings are limited due to a small pool of literature. Cultural variations in NSSI presentation should be considered when working with Indigenous populations. Further research is required to help determine what cultural variations may exist.     

Aboriginal perceptions of social and emotional wellbeing programs: A systematic review of literature assessing social and emotional wellbeing programs for Aboriginal and Torres Strait Islander Australians perspectives

Australian Aboriginal and Torres Strait Islander communities have been targets of social and emotional wellbeing programs for many years. However, the few health-care programs and services that are evaluated rarely provide insight into the participants' perspectives of program success or failure. This systematic review assessed 33 social and emotional wellbeing programs across Australia to better understand what Aboriginal community members think about the programs and how they could be improved. Results highlighted the interesting and valuable insights provided by Aboriginal participants, including what kinds of program activities and approaches are most suitable, what program characteristics are successful or desired, and their experiences of wellbeing change before and after program participation. They likewise voiced opinions about poorly received programs, culturally inappropriate services and negative experiences. This review highlighted how health and wellbeing programs must better engage Aboriginal and Torres Strait Islander clients to ensure that services are culturally safe, holistic, integrate appropriate staffing, include culturally relevant activities and value patient/participant experiences. These findings have significant implications for the health and wellbeing sector; specifically, research, policy, program design and implementation, evaluation methods, and self-determination.     

Contextual Factors for Research on Psychological Therapies for Aboriginal Australians

This paper is to provide a commentary to Can cognitive behavioural therapy (CBT) be effective for Aboriginal Australians? Perspectives of Aboriginal practitioners trained in CBT. It is inspiring that this study has found that CBT can play a useful role in therapy for Aboriginal and Torres Strait Islander people but the outcomes need to be considered with caution. CBT can provide a useful tool when working with Aboriginal and Torres Strait Islander people, but in itself is not adequate for a number of reasons. Firstly, it is not culturally responsive but can be part of an approach that might be culturally appropriate. The authors are compelled at this point to give a history of mental health and Aboriginal and Torres Strait Islander people to provide a background context to the discussion and to illustrate why some psychological approaches such as CBT can only ever be part of the tools that might be used in a broader framework, that is required to address and strengthen Aboriginal and Torres Strait Islander people's well‐being.     

“Like Drawing Into Sand”: Acceptability,Feasibility, and Appropriateness of a New e‐Mental Health Resource for Service Providers Working With Aboriginal and Torres Strait Islander People

Cross‐cultural considerations and difficulties recruiting and retaining skilled workers in rural and remote regions may contribute to poorer service use for Aboriginal and Torres Strait Islander people. However, electronic resources may provide the opportunity for remote workforces to deliver structured, evidence‐based, culturally appropriate treatments with limited training burden. The aim was to develop and determine the acceptability, feasibility, and appropriateness of a new e‐mental health resource (the Australian Integrated Mental Health Initiative [AIMhi] Stay Strong App) for service providers working with Aboriginal and Torres Strait Islander people in the Northern Territory. Eleven semi‐structured interviews were conducted with 15 service providers and managers from a range of rural and remote primary health care service settings in the Northern Territory. All participants were given the resource to trial for at least 1 month before being interviewed about perceived barriers and enablers, acceptability, and feasibility. Thematic analysis revealed support for the acceptability, feasibility, and appropriateness of the resource among service providers. Major themes identified included acceptability, building relationships, broad applicability, training recommendations, integration with existing systems, and constraints to implementation. This is one of the first studies to explore the acceptability of e‐mental health approaches for Aboriginal people among the remote health workforce. It is likely that e‐mental health interventions, such as the AIMhi Stay Strong App will assist services to deliver evidence‐based, structured interventions to improve well‐being for Aboriginal and Torres Strait Islander clients.     

Critical reflections on teaching challenging content: do some students shoot the (white) messenger?

Racism is an enduring reality in Australian society for Indigenous Australians, reflecting the experiences of Indigenous peoples in colonized countries worldwide. While social work services delivered by Indigenous Australians might be the preferred option, the graduation rate of Aboriginal and Torres Strait Islander students from Australian social work training is low and non-Indigenous social workers provide most service delivery. As a non-Indigenous social work educator at an Australian university, I recognize that teaching culturally relevant curricula, in order to produce antiracist social work graduates who recognize racism and privilege, is crucial but challenging. The purpose of this article is to share my ongoing critical reflections, particularly with regard to student dissatisfaction and possible disengagement with difficult content, and my actions for improved teaching and learning, in order to graduate work-ready social workers.     

Perceived Burdensomeness Predicts Outcomes of Short‐Term Psychological Treatment of Young People at Risk of Suicide

The interpersonal‐psychological theory of suicide (IPTS; Joiner, 2005 ) provides a model for understanding the mechanisms underlying suicide risk, but there is limited research measuring change in the constructs over the course of treatment. This study aimed to test whether changes in perceived burdensomeness (PB) and thwarted belongingness (TB) mediated the effects of changes in depression and hopelessness on suicide risk. The sample comprised 226 Australian young people (aged 12–24; 67.7% female; 5.7% Aboriginal and Torres Strait Islander) receiving short‐term psychological treatment for suicide‐related behaviors. Change scores over the course of therapy were generated using admission and discharge measures of PB, TB, depression, hopelessness, and suicide risk. Results revealed partial support for the theory. The relationship between changes in depression and hopelessness on suicide risk was fully mediated by changes in PB. However, changes in TB did not mediate these relationships. This study offers encouragement for the potential use of the IPTS in the context of psychological treatment of young people. Assessment of the IPTS constructs may be helpful in assessing change in suicide risk and further assist in treatment.     

Whole of community suicide prevention forums for Aboriginal Australians

It is well known that Aboriginal Australians are at increased risk of suicide. Contributors to suicide differ for Indigenous and non-Indigenous populations (Westerman, 2003; 2019). This study evaluated whole of community suicide prevention forums conducted across six locations. Attendees were youth (N = 136), service providers (N = 225), and community members (N = 158). The content of the forums was empirically based and, for service providers and community members, covered knowledge of suicide, and depression specific to Aboriginal people, skills relating to working with depressed and suicidal Aboriginal people, and intentions to help an Aboriginal person who is suicidal. Content for youth attendees focused on knowledge of suicide and depression, coping skills, intentions to help a friend, and beliefs about suicide. While the results demonstrated significant gains across most domains, there was a potentiating effect with some skills increases becoming more significant over each phase. This demonstrates that a whole of community approach to Indigenous suicide prevention is required, and that clinical and cultural skills require a longer-term approach for impact and sustainability.     

A review of Evidence‐Based Evaluation of Measures for Assessing Social and Emotional Well‐Being in Indigenous Australians

Addressing low levels of social and emotional well‐being (SEWB) in Indigenous communities has been a national strategic priority for over 10 years and yet progress in assessing the impact of interventions has been slow. One of the key factors limiting the development of evidence‐based practice has been the lack of well‐validated instruments to assess SEWB and how it changes over time as a result of intervention. This article systematically reviews available measures, classifying them in terms of the evidence base that exists to support their use. It is concluded that there is an ongoing need to develop psychometrically sound, comprehensive, culturally appropriate measures to operationalise Indigenous SEWB at a population health, programme evaluation, and clinical level. It is suggested that seven pathways be followed to achieve this goal, including the need to recognise that the gold standard status for Indigenous measurement tools cannot be ascribed based on evidence‐based assessment criteria alone.     

Aboriginal Practitioners Offer Culturally Safe and Responsive CBT: Response to Commentaries

We appreciate the valuable commentaries that have been provided for our paper “Can CBT be effective for Aboriginal Australians? Perspectives of Aboriginal practitioners trained in CBT.” The international authors identify how CBT, with adaptations by culturally responsive practitioners can be of value for non‐Western and Indigenous peoples. The commentary by Australian psychologists Dudgeon and Kelly questions the value of CBT for Indigenous Australians, terming it a “Western therapy” that is “culturally unresponsive” and “culturally blind.” They also critique the methodology of the study. We argue that CBT can be adapted by culturally competent practitioners to be culturally safe in Australia, as elsewhere. Cultural safety is mostly a function of the therapist, not the therapy. In the Bennett‐Levy et al. (2014) study, CBT was delivered in a culturally responsive way by Aboriginal counsellors within their own communities. CBT is a particularly adaptable and versatile therapy, and embodies principles of empowerment and self‐determination that are central to Indigenous social and emotional well‐being. We are concerned that CBT, which has strong empirical support and has been adapted elsewhere for a range of cultures, including Indigenous cultures, may be being denied to Indigenous Australian clients. There is considerable opportunity to evaluate the effectiveness and versatility of CBT, and variations of its mode of delivery, for all Australians.     

Reducing drug and alcohol use and improving well-being for Indigenous and non-Indigenous Australians using the Community Reinforcement Approach: A feasibility and acceptability study

There is a lack of evidence of effective and appropriate drug and alcohol treatment for Aboriginal and Torres Strait Islander peoples. This paper contributes to addressing the evidence gap by examining the feasibility and acceptability and conducting a pre/post-evaluation of the Aboriginal-adapted Community Reinforcement Approach (CRA) delivered in New South Wales, Australia. Aboriginal and non-Aboriginal clients (n = 55) received tailored CRA delivery between March and November 2013. Compared to the original US version, tailored CRA had reduced technical language, reduced number of treatment sessions, and the addition of group delivery option. An Australian training manual with local case studies was developed. Alcohol, Smoking and Substance Involvement Test (ASSIST), Kessler-5 (K-5) and the Growth Empowerment Measure were used. 58% of participants were followed-up at 3 months. Tailored CRA was feasible to deliver in a rural, community-based health setting, and rated by clients as highly effective and acceptable. CRA was associated with statistically significant reductions in the use of alcohol, tobacco, cannabis, amphetamine and over the counter medication, and levels of psychological distress, and an increase in levels of empowerment for Aboriginal and non-Aboriginal clients. This study provides evidence for the feasibility and acceptability of an Aboriginal-adapted psychological intervention addressing drug, alcohol and mental health outcomes.     

The Weaving Healthy Families program: Promoting parenting practices,family resilience,and communal mastery

Parenting quality, family resilience, and community resilience and support have been found to be primary protective factors for the disproportionate burden of anxiety, posttraumatic stress disorder (PTSD), substance use disorder (SUD), depression, and suicide that US Indigenous youth and adults tend to experience. The purpose of this research study was to examine pilot results for outcomes related to relational factors for Indigenous family members who participated in the Weaving Healthy Families (WHF) program (translated to Chukka Auchaffi’ Natana, in the Choctaw tribal language), a culturally grounded and empirically informed program geared toward promoting wellness, family resilience, parenting practices, and community resilience while also preventing SUD and violence. This nonrandomized pre-experimental pilot intervention followed a longitudinal design, which included pre-test, a post-test, and a 6-, 9-, and 12-month post-intervention follow-up surveys. Repeated-measures regressions were utilized with generalized estimating equations (GEE) to examine changes in parenting, family resilience, and communal mastery before and after the intervention for 24 adults and adolescents (12–17) across eight tribal families. Results indicate that the overall quality of parenting improved, as measured by improved parental monitoring and reductions in inconsistent discipline and corporal punishment. We identified sex differences in positive parenting, poor monitoring, and corporal punishment, with greater decreases in these measures among males over time. Family resilience and communal mastery improved for adolescent and adult participants after the WHF program. Our results indicate promising improvements across relational, familial, and community ecological, which provide clear clinical implications.     

Working in Indigenous Contexts: Self‐Reported Experiences of Non‐Indigenous Australian Psychologists

Despite assertions in the literature that psychologists adopt culturally inappropriate strategies for working with Indigenous clients, there is little empirical evidence about this. The aim of this study was to document the self‐reported experiences of non‐Indigenous psychologists working with Indigenous clients, the factors that they felt constrain these interactions, and the clinical, assessment and communication strategies they perceived as effective in Indigenous contexts. Structured interviews were held with 23 psychologists, 18 females and five males, with age groups ranging from 20–30 to 50+. Thematic analysis of the data revealed that participants experienced contradictions between the typical Western white psychologists' ways of interacting with clients, which they had been taught and the typical ways in which relationships are structured in Indigenous communities. The results suggest that the Western model of psychological training does not work very well in Indigenous contexts, and that psychologists working in Indigenous contexts have to work out their own methods on a trial‐and‐error basis. This points to the need for more systematic cultural competence training. However, there is a lack of research into the effectiveness of psychological intervention from the viewpoints of Indigenous clients themselves.     

Issues in Professional Training to Implement Evidence‐based Parenting Programs: The Preferences of Indigenous Practitioners

Indigenous children have elevated risk for poor health, behavioural, emotional, and social outcomes. Significant evidence exists that parenting programs can reduce family risk factors and improve outcomes for children and families; however, mainstream programs have had slower uptake in Indigenous communities than other communities. Culturally sensitive delivery of evidence‐based programs can enhance engagement of parents, yet the development of a workforce to deliver programs to Indigenous parents faces many obstacles. This project seeks to identify professional training processes that enhance Indigenous practitioners’ skills and confidence in delivering an evidence‐based parenting program. A survey of trained parenting practitioners via an online practitioner network assessed their views of the training and post‐training support processes they had experienced. Respondents were 57 Indigenous and 720 non‐Indigenous practitioners from 15 countries. Most training processes were rated equally helpful by Indigenous and non‐Indigenous practitioners. However, several training processes were identified as important for the delivery of culturally competent training, such as tailoring the pace of training and simplifying the language in teaching resources. Practitioners with higher ratings of the helpfulness of peer support following training reported higher program uptake and implementation. Qualitative themes also focused on the helpfulness of program resources, and having a peer support network and mentoring. Increasing access to appropriate, flexibly delivered training and post‐training support for Indigenous professionals will support the development of a skilled workforce with local knowledge and connections, and further increase the reach of evidence‐based services in Indigenous communities.     

Impact of Client Suicide on Psychologists in Australia

Objective

This research aimed to assess the frequency and impact of client suicides on psychologists in Australia.

Method

Participants were 178 psychologists who completed an online self‐report questionnaire concerning the frequency of occurrence and impact of client suicide.

Result

Fifty six (31.5%) participants reported one or more client suicides. Psychologists with more years of experience reported more client suicides. Participants who had experienced a client suicide reported a range of emotional, cognitive and behavioural reactions as well as professional impacts. Ratings of responsibility, preventability and predictability of a client suicide were associated with emotional and/or professional impacts. Beneficial coping responses included talking to supervisors and colleagues, recognising the psychologist is not responsible and having increased acceptance of a client suicide.

Conclusions

The findings have important implications for training, workplace practices and research.     

“When you're coming from the reserve you're not supposed to make it”: Stories of Aboriginal athletes pursuing sport and academic careers in “mainstream” cultural contexts

ObjectivesThis project responds to the call for athletic career development and transitions research that centralizes the constitutive role of culture in athletes' experiences (Stambulova & Alfermann, 2009; Stambulova & Ryba, 2014). Within, we explore the cultural transitions of Aboriginal hockey players (14–22 years old) relocated into “mainstream” (Euro-Canadian) cultural contexts to pursue dual careers as students and athletes.DesignThe research was framed as a cultural sport psychology initiative. The project was rooted in a local Indigenous decolonizing methodology, which was brought forward via a participatory action research approach.MethodsMandala drawings and conversational interviews were employed as open-ended data collection processes that enabled the participants to share their stories and meanings through their own cultural perspectives. Vignettes were then used to present their accounts.ResultsThe participants' careers as athletes and students were precariously navigated within larger cultural tensions to: (a) deal with a loss of belonging in the Aboriginal community; (b) break down negative stereotypes and attitudes that Aboriginal people are not able to “make it”; and (c) give back to the Aboriginal communities they relocated away from.ConclusionsThrough a culturally resonant mode of knowledge production, the research uncovers contextual understandings of the cultural transitions experienced by Aboriginal athletes, revealing how this transition intersects with and shapes their dual careers. The project offers insight into the central role of culture in shaping athletes' dual careers, and provides impetus for more idiosyncratic approaches to be adopted in future research.     

The interface of mental and emotional health and pregnancy in urban indigenous women: Research in progress

Research among indigenous women in Australia has shown that a number of lifestyle factors are associated with poor obstetric outcomes; however, little evidence appears in the literature about the role of social stressors and mental health among indigenous women. The not‐for‐profit organization beyondblue established a “Depression Initiative” in Australia. As part of this they provided funding to the Townsville Aboriginal and Torres Strait Islander Health Service in the “Mums and Babies” clinic. The aim of this was to establish a project to (a) describe the mental health and level of social stressors among antenatal indigenous women and (b) assess the impact of social stressors and mental health on perinatal outcome. A purposive sample of 92 indigenous women was carried out. Culturally appropriate research instruments were developed through consultations with indigenous women's reference groups. The participants reported a range of psychosocial stressors during the pregnancy or within the last 12 months. Significant, positive correlations emerged between the participants' Edinburgh Postnatal Depression Scale (EPDS; J. Cox, J. Holden, & R. Sagovsky, 1987) score and the mothers' history of child abuse and a history of exposure to domestic violence. A more conservative cutoff point for the EPDS (>9 vs. >12) led to 28 versus 17% of women being identified as “at risk” for depression. Maternal depression and stress during pregnancy and early parenthood are now recognized as having multiple negative sequelae for the fetus and infant, especially in early brain development and self‐regulation of stress and emotions. Because of the cumulative cultural losses experienced by Australian indigenous women, there is a reduced buffer to psychosocial stressors during pregnancy; thus, it is important for health professionals to monitor the women's emotional and mental well‐being.     

Navigating the insider-outsider hyphen: A qualitative exploration of the acculturation challenges of Aboriginal athletes pursuing sport in Euro-Canadian contexts

ObjectivesThe purpose of this project was to explore the acculturation challenges of Aboriginal athletes (14–26 years) from Canada as they moved off reserves to pursue sport within non-Aboriginal (Euro-Canadian) communities. The project was also aimed at contributing to the acculturation literature in sport psychology through an Indigenous decolonizing methodology.DesignUniversity academics partnered with Aboriginal community researchers from one reserve to facilitate an Indigenous decolonizing methodology rooted in practices from the local culture. The project was articulated as a form of cultural sport psychology.MethodsMandala drawings were used to facilitate conversational interviews with 21 Aboriginal athletes about their experiences relocating off reserves and the acculturation challenges they faced as they attempted to pursue sport within Euro-Canadian contexts. A local Indigenous version of an inductive thematic analysis was then conducted.ResultsThe acculturation challenges of Aboriginal athletes coalesced into two major themes: (a) culture shock (which occurred in relation to the host culture), and (b) becoming disconnected from home (which occurred in relation to the home culture). These themes illustrated how the athletes’ sense of identity and place were challenged and changed, as they (re)negotiated meaningful positions for themselves in and between two cultural realities.ConclusionThis project centralized a culturally resonant mode of knowledge production embracing local Aboriginal ways of knowing. This approach facilitated deeper insights into athletes’ acculturation challenges, which contextualized the complexity and fluidity of the acculturation process.     

Substance use patterns of young offenders and violent crime

The use of alcohol is a significant predictor of the involvement of young offenders in violent crime. This study found that in a sample of 300 incarcerated juveniles in New South Wales, more than 70% admitted to violent crime. Detainees from an Aboriginal or Torres Strait Islander culture were less likely than other detainees to be involved in violent crime. The substances most associated with violent crime were alcohol, followed by cocaine. However, when the likelihood that the young person has initiated violence as a response to alcohol or other substances is introduced into the equation, the direct effects for alcohol and cocaine predicting engagement in violent crime disappear. The Goldstein hypothesis that the effects of a substance directly facilitate violence, thereby accounting for the relationship between substances of use and violent crime, was supported. Aggr. Behav. 29:414–422, 2003. © 2003 Wiley‐Liss, Inc.     

Beyond the Belmont Principles: A Community‐Based Approach to Developing an Indigenous Ethics Model and Curriculum for Training Health Researchers Working with American Indian and Alaska Native Communities

Individuals responsible for carrying out research within their diverse communities experience a critical need for research ethics training materials that align with community values. To improve the capacity to meet local human subject protections, we created the research Ethics Training for Health in Indigenous Communities (rETHICS), a training curriculum aligned within American Indian and Alaska Native (AI/AN) context, culture, and community‐level ethical values and principles. Beginning with the Belmont Report and the Common Rule that defines research with human subjects (46 CFR 45), the authors convened three different expert panels (N = 37) to identify Indigenous research values and principles common across tribal communities. The resulting culturally grounded curriculum was then tested with 48 AI/AN individuals, 39 who also had recorded debriefing interviews. Using a thematic analysis, we coded the qualitative feedback from the expert panel discussions and the participant debriefings to assess content validity. Participants identified five foundational constructs needed to ensure cultural‐grounding of the AI/AN‐specific research training curriculum. These included ensuring that the module was: (a) framed within an AI/AN historical context; (b) reflected Indigenous moral values; (c) specifically linked AI/AN cultural considerations to ethical procedures; (d) contributed to a growing Indigenous ethics; and (e) provided Indigenous‐based ethics tools for decision making. Using community‐based consultation and feedback from participants led to a culturally grounded training curriculum that teaches research ethical principles and procedures for conducting research with AI/ANs. The curriculum is available for free and the community‐based process used can be adapted for other cultural groups.     

The Experiences of Indigenous Australian Psychologists at University

Disparities exist between Indigenous Australians and non‐Indigenous Australians on indicators of life expectancy, alcohol and drug use, adult and juvenile incarceration, and rates of hospitalisation for self‐harm, suicide, and mental and behavioural disorders due to psychoactive substance use. Psychology is a discipline that can assist in remedying these issues, yet disparities are evident in Indigenous participation in higher education generally, as well as within tertiary psychology education specifically. Ten Indigenous Australian psychologists were interviewed to investigate possible barriers and enablers for Indigenous students studying psychology at university. Hermeneutic phenomenology guided the research and its analysis, whereby the data went through a process known as the “hermeneutic circle”; data were analysed in itself, as well as part of the whole, leading to the world views of the participant and researcher converging into a “horizon of meaning.” Sources of support for Indigenous students included family support, financial assistance, and Indigenous student support centres. Potential barriers to university study of psychology were negative conceptions of higher education and psychology by the Indigenous community, “culture shock” upon relocating to the metropolitan area, a lack of Indigenous content and staff, and culturally insensitivity by staff members. Efforts should be made to address these barriers to participation, as well as to support those structures and services that were supportive for students.