By Sarah Ford, InPsych feature writer
DOCTOR Tracy Westerman's childhood yearning to be a psychologist lost its edge when the young Aboriginal student began her studies in Perth. After leaving her family in remote Western Australia to attend university, she struggled to reconcile her concept of psychology with the Western-oriented views taught in psychology courses.
"I thought 'this is not what psychology is meant to be about', because it did not match the world view that I had been bought up with," she says.
The course made virtually no reference to non-Western cultures and she grappled to conceptualise mainstream theories in a way that was meaningful for Aboriginal people. Nevertheless, Tracy, who is from the Nyamal group in north-western WA, persevered to become one of a handful of Aboriginal psychologists in Australia.
She recently completed her PhD in Clinical Psychology, focusing on the psychological assessment of Aboriginal people, and has developed a screening tool to identify cultural resilience and at-risk behaviours in Aboriginal adolescents. Her scholarly achievements were rewarded last year with a National Aboriginal and Islander Day of Commemoration (NAIDOC) Award.
Tracy is the Managing Director of Indigenous Psychological Services (IPS), a Perth-based company that provides culturally appropriate clinical, assessment and training services around Western Australia.
Cultural incompetence a major problem
IPS is trying to fill a gaping hole in Australian psychological practice by providing training in culturally appropriate standards for working with indigenous people.
Tracy says that Western practitioners "genuinely struggle" when working with Aboriginal people because they lack minimum standards of cultural competence that are definable and measurable. "People say they want to be culturally appropriate, but no-one knows when they are," she says.
Take psychological testing, for example. "When working with Aboriginal people, Western practitioners often avoid using tests altogether, or they use mainstream tests despite concerns expressed over their cultural validity," Tracy says.
IPS has developed a cultural competence instrument that assesses practitioners' knowledge and skills in working with Aboriginal people. It measures the efficacy of therapists' strategies by asking questions such as: Am I able to engage with Aboriginal people as effectively as I am able to engage with non-Aboriginal people? When I work with an Aboriginal client am I able to use a range of therapeutic techniques?
Clinical psychologist Dave Vicary has often asked himself these same questions since the mid-1980s when he began working in remote Aboriginal communities in the north-western desert regions of Western Australia. After a while he concluded that "a lot of what I had been taught did not necessarily match up with working effectively with Aboriginal people."
This realisation eventually inspired the now Executive Director of the Office for Children and Youth at the Department for Community Development in Western Australia to do a PhD on the topic. Dave's research involved a qualitative study of 70 Aboriginal people from Western Australia that explored their views of Western therapy (Vicary, 2003). The process was guided and reviewed by an Aboriginal steering group.
Many participants reported a preference for traditional healers over non-Aboriginal services, which they would only access if there was no other option. A common perception was that Western therapy was culturally inappropriate or irrelevant. The study also identified a distrust of the Western medical health system, Dave says.
"Some Aboriginal people have a very real fear of coming into contact with the 'white' mental health system because in the past, relatives have been sent to mental health hospitals away from their communities," he says.
Adjusting Western psychological practices is critical
"It was having to make adjustments to my practice, particularly rethinking some of the strategies I had used to engage Aboriginal people, that really peaked my interest to go and do my PhD," Dave says.
Unlike the professional nature of counsellor/client relationships typical of Western cultures, Aboriginal people prefer to "just to have a relationship," he says.
"There is no professional/personal dichotomy, which means they are quite happy to come and have a yarn to you in the shops, or catch you on a Saturday to talk things through.
"If you expect to see people pouring in your door at the office, it won't happen. You have to work more flexibly and actually meet people where they feel comfortable, like in a park, or going for a drive or a walk."
Dave has also adjusted to the common Aboriginal practice of third-person referrals, which is in line with the traditional way that Aboriginal people make referrals to their own healers.
After initially ignoring such requests because the person hadn't been referred in writing or had not referred themselves, "I started realising that there was a whole raft of referrals that perhaps I had been missing," Dave says.
To ensure an ethically correct and culturally appropriate referral process, he relies on Aboriginal colleagues who would generally know most people in the community. Usually the colleague will ask the potential client's family if they can chat to him/her and, if granted approval, they then check that he/she has agreed to see Dave before the meeting takes place.
Dave says that he always works with an Aboriginal cultural consultant who is generally selected by the client and actively participates in the therapy. "The relationship is very reciprocal and I would learn as much from them as they learn from me," he says.
This process also helps him avoid slip-ups, although the odd one is inevitable. "I have always asked permission to make mistakes and that people let me know when I do make those mistakes," he says. "I get them pointed out to me fairly regularly."
One early mistake was his decision to use Rational Emotive Therapy (RET) to treat an Aboriginal man with depression. "I thought RET was the perfect therapy because I had only been out of uni for a couple of weeks," Dave says. "Unfortunately (the client) didn't think that it was the best therapy and every time I then went to town I was referred to as 'RET'.
"The biggest mistake is when something doesn't fit and you try to make it."
Aboriginal versus Western concepts of mental health
Working with a consultant also improves Dave's understanding of Aboriginal concepts of mental health. Compared with the Western mind/body split view of health, Aboriginal people perceive health holistically where being 'well' includes physical, mental, cultural and spiritual elements.
"For a long time I just couldn't grasp a lot of their concepts because it is quite complicated," Dave says. "But I have been really fortunate in that I have worked with a lot of Aboriginal people who have given their time and patience to make sure that I do understand."
It is these different conceptualisations of mental health that Tracy first grappled with back in her university days. For Aboriginal people, culture and health are intrinsically tied such that culture is often considered the cause of illness, which Tracy says is not explored in conventional psychological assessments.
Much of her work involves identifying culture-bound illnesses.
"Aboriginal people relate everything to culture instead of mental illness," she says. For example, a suicide does not mean that someone killed themselves. Rather, they were being 'paid back' for a transgression, or they were 'sung', which means they were cursed.
Another example is being 'sick for country', which appears to be depression, but is due to being removed from one's country (birthplace/Dreaming) for long time periods, Tracy says.
"You see that a lot in the Stolen Generations; people who quite often have dissociative fugues associated with being removed from land and country."
Grounding Western psychology in Aboriginal culture
Tracy says the key to applying Western psychology in an Aboriginal context is to ground its practice in Aboriginal cultural strengths.
This involves building on the evidence-based knowledge of existing strengths, such as Aboriginal preferences for learning by imitation and observation, and relating on a practical rather than an abstract level.
"For example, with anger management we look at mirroring a bodily response to an Aboriginal person who might have anger issues, so you learn by vision and imitation, rather than the verbal and abstract," Tracy says.
Using visual skills is also practical as it relies on tools that are more available and familiar than, for instance, written material such as diaries that are common in Western therapies.
Western therapeutic techniques are typically abstract, so the challenge is to develop methods that do not rely so much on relating to affect or emotion, but focus more on a situational or physical context.
For example, when working with a suicidal client you might ask: "The last time you tried hurting yourself...what was the main yarn you were telling yourself, or what were you feeling on your body?" Tracy says.
Many counselling skills are not appropriate for working with Aboriginal people so it is important to tease out suitable methods from those that need to be adapted to reflect Aboriginal world views. For instance, using reflective feedback is not appropriate for engaging with Aboriginal people.
"You need to engage at a narrative level around yarning, so if you reflect the content of discussion you are disjointing that yarn," Tracy says.
Respecting culture opens doors
Respecting cultural protocols is vital for successfully engaging with Indigenous clients, as psychologist Marlene Izod has discovered in her 15 years of working with Aboriginal people.
Marlene is the Director of Trauma Services at the Employee Assistance Services in the Northern Territory, a job that has taken her to most of the Territory's remote communities, as well as the Tiwi Islands, East Timor and Indonesia.
Over the years she has learnt how Aboriginal people value respect and how their notions of respect differ from Western views. Simple yet critical gestures include taking cues on appropriate ways to dress, talk and use body language when visiting traditional communities. "In some communities it is not polite to wear short shorts," she says.
On arriving in a community Marlene also alters her usual approach of introducing herself and her work role: "I draw a little diagram and tell them about me and how I sit within my family."
"It is important to be humble and respectful," she says. "But to also hold your ground as someone representing your culture and not pretending you are something else, or one of them."
Often her work involves breaking down cultural barriers and opening lines of communication between Aboriginal and non-Aboriginal people. The training she provides staff working at a health clinic might include a session on how to communicate effectively and appropriately with each other's culture.
The value of learning from each other resonates with Marlene. She says that Aboriginal approaches to various issues have enhanced her practise with all clients, indigenous or not.
The way many Aboriginal mothers handle their children with lots of touching and stroking has informed her work on attachment with non-Aboriginal clients.
Observing how Aboriginal people handle grief, which in her experience involves less talk and more touch than in Western cultures, has also greatly influenced her work.
Cultural training is the key
While experienced and culturally aware practitioners like Marlene and Dave are an invaluable resource, encouraging more Aboriginal people into the psychology profession is the ultimate goal.
Tracy says that including cultural issues in psychologists' core training is vital to achieving this aim.
The fact that Aboriginal mental health issues are not part of core training in psychology courses is a "disgrace", especially considering that Aboriginal people experience the highest rate of mental illness in Australia, she says.
"I think psychology needs to start being genuine about the desire to make the profession more culturally appropriate."
The APS Ethical Guidelines on working with Aboriginal clients are "an important step", but should be incorporated into the Code of Ethics itself rather than as an appendix "because most people are still unaware they exist", Tracy says.
Change within the profession may be frustratingly slow for some, but trailblazers like Tracy are bridging the cultural gaps to lay stronger foundations for the future.
For a guide to working with Aboriginal clients see:
P. Dudgeon, H. Pickett, & D. Garvey (Eds.). (2000). Working with Indigenous Australians: A Handbook for Psychologists. Perth: Gunada Press.
APS members can download the Guidelines for the provision of psychological services for, and the conduct of psychological research with, Aboriginal and Torres Strait Islander People of Australia from the APS website.
Vicary, D.A. (2003), 'Counselling as Yarning: Aboriginal insights into Western therapy'. Proceedings of the 38th APS Annual Conference, Australia, 242-246.