Chapter 18 Mental Health Services

• Existing services
• Evaluation government objectives
• Evaluation Inquiry criteria
• Recommendations

There is no Aboriginal family that is untouched by this policy. Many Aboriginal organizations today attempt to help Aboriginal adults who were 'removed' children to patch up their lives. Yet even today no official recognition is given to what happened. One problem of this blinkered approach by officialdom is that much needed support services are not provided to many people who literally 'live on the edge' (Secretariat of National Aboriginal and Islander Child Care submission to the Royal Commission into Aboriginal Deaths in Custody, quoted in National Report Volume 2 on page 11).

Mental health needs

Indigenous mental health is finally on the national agenda. As participants in the National Mental Health Strategy, States and Territories acknowledge the importance of the issue. Some of the effects of removal including loss and grief, reduced parenting skills, child and youth behavioural problems and youth suicide are increasingly recognised.

The circumstances in which a large proportion of Indigenous people live also contribute to experiences of loss and grief and to mental health and related problems. They include poverty and high rates of unemployment, marginalisation and racism. This complex of factors is noted in the Queensland Mental Health Policy Statement for Aboriginal and Torres Strait Islander People (June 1996) and in the final submission to the Inquiry by the South Australian Government.

Mental health status for all people is the result of a dynamic and interactive process involving social, environmental and life circumstances, as well as biological factors. For Aboriginal and Torres Strait Islander people in general, there are significantly higher levels of stress and anxiety in their lives resulting from the consequences of trauma and grief, which are inextricably linked to mental health and disorder.

The history of colonisation of Australia has had a profound effect on Aboriginal and Torres Strait Islander people. They have, as a group, experienced considerable trauma in the form of dispossession of land, removal of children, family separation and displacement, and loss of culture. In the present day, many Aboriginal and Torres Strait Islander people continue to live in conditions of social and economic disadvantage compared with the population as a whole, and exhibit high levels of unemployment, lack of appropriate housing and other basic services.

A very significant issue in this context which was highlighted in community consultations is the need to understand and address grief and loss relating to the social and historical context of Aboriginal and Torres Strait Islander life (Queensland Mental Health Policy Statement pages 9-10).

Issues relating to socio-cultural determinants, historical and political events, racism, cultural genocide and communal self-worth all impact on the scope of Aboriginal 'mental health'. The area of Aboriginal mental health is poorly understood; few experts would claim to fully understand the normal Aboriginal psyche or to confidently diagnose deviations ... Many of the so called mental health issues in the Aboriginal Community result from striving to fulfil the expectations of two different cultures - about finding a sense of place (South Australian Government final submission page 54).

The complexity of the causes of mental health problems for Indigenous people and their entrenched nature need to be recognised in the development of responses and treatments.

The National Mental Health Strategy is a joint Commonwealth-State funding program which includes a component for Indigenous people as a special needs group. This joint initiative is a five year program (1992-93 to 1997-98) with a broad objective of spurring mental health reforms (Commonwealth Government submission page 11).

Indigenous health generally was the focus of the 1990 National Aboriginal Health Strategy. This Strategy was developed by the National Aboriginal Health Strategy Working Party which reported in 1989. On mental health the Working Party concluded that,

Mental distress is a common and crippling problem for many Aboriginal people and appropriate services are a pressing need. Advances in the understanding and treatment for mental health problems have been impressive since World War II; this progress has yet to benefit Aboriginal people. Culturally appropriate services for Aboriginal people are virtually non-existent. Mental health services are designed and controlled by the dominant society for the dominant society. The health system does not recognise or adapt programs to Aboriginal beliefs and law, causing a huge gap between service provider and user. As a result, mental distress in the Aboriginal community goes unnoticed, undiagnosed and untreated (pages 171-172).

Indigenous use of services

Indigenous people are generally under-represented as clients of mental health services, especially primary and secondary services (NSW Government interim submission page 106, Adams 1996 page 1, Dr Jane McKendrick submission 310 page 32, Swan and Fagan 1991 page 24). However all governments now accept that proportionally at least as many Indigenous people suffer mental health problems but that mainstream services have not been accessible or appropriate. The Queensland Government has additionally recognised that 'because of the conditions of life for many Aboriginal and Torres Strait Islander people, other disorders appear to have higher rates. These include anxiety and adjustment disorders, substance induced psychotic disorders, cognitive impairment in older people, and conduct disorders in children' (Mental Health Policy Statement 1996 page 10).

The reasons for Indigenous under-representation as clients were analysed for the Inquiry in a number of submissions.

There is an enormous amount of ignorance, lack of understanding, lack of tolerance and unfounded beliefs associated with Aboriginal and Torres Strait Islander people's mental health issues among mainstream services. Mainstream services lacked knowledge and/or were insensitive to cultural issues of history, culture, spirituality, trauma, loss and grief. These features were virtually universal to all Aboriginal people who experienced mental distress. Other problems relevant to poor acceptability and accessibility of the mainstream services related also to racial prejudice and discrimination, lack of respect, and in many cases poor previous experience in mainstream services both rural and urban (Sydney Aboriginal Mental Health Unit submission 650 page 2). Such services [ie conventional, mainstream, mental health services] are culturally inappropriate for Aboriginal people and do not meet their needs. Aboriginal people do not feel comfortable using mainstream health services ... It is vital to Aboriginal people that they know and are known by those they trust to work with them (Dr Jane McKendrick, Victorian Aboriginal Mental Health Network, submission 310 pages 32-33).

The national consultancy on Indigenous mental health commissioned by the Commonwealth under the National Mental Health Strategy found widespread agreement with this assessment.

Consumers and families have frequently described the failure to inform them, to explain, to provide optimal care and there is a pervasive view that diagnosis and treatment are 'second class' for Aboriginal people with mental illness (Swan and Raphael Ways Forward 1995 page 32).

The authors concluded,

[There was] extensive evidence of the inadequacy of current mental health services for Aboriginal people. In many remote and rural communities these were virtually non-existent. Where there was contact with or use of mainstream mental health services they were frequently seen as unhelpful, non responsive, inaccessible or unavailable and totally failing to respond to the needs of Aboriginal people with mental illness. Misdiagnosis, the inappropriateness of Western models, failure to recognise language differences, ignorance of Aboriginal culture and history, and racism complicated the picture ... the overall picture is one of gross inadequacy ... (Swan and Raphael Ways Forward 1995 page 38).

Misdiagnosis with its consequent inappropriate treatment or even failure to treat is a critical problem.

... in a lot of cases from my experience, Aboriginal people are often misdiagnosed as having a personality disorder when they are in fact depressed. And that will come about because psychiatrists might hear that they have been in gaol or that they have been abusing substances and so immediately the diagnosis is closed. The diagnosis of personality disorder - which is actually more a moral diagnosis and implies you cannot help the person - is given.

There are other cases where a person has very obviously got a very serious psychotic disorder and they present to a hospital and if they smell of alcohol at all they might be refused admission. Or if they have committed a minor offence they might be refused admission. It seems that the obvious psychotic symptoms are missed and the person is said just to have a personality disorder. In other cases psychiatrists do not understand Aboriginal culture and so they might misdiagnose a severe depression as being psychosis because of certain symptoms that occur in normal grief reaction (Dr Jane McKendrick, Victorian Aboriginal Mental Health Network, evidence 310). ... there have been a lot of Aboriginal women over the last 10 to 15 years who have been labelled with mental illnesses, with mental health disorders. I believe, through information from Department of Health, that those women really didn't have psychotic episodes or anything like that; that it was part of them not knowing who they were and struggling within themselves, between being ripped in trying to find out who they are, the difficulties in putting yourself in the public eye and asking for help to find your family, to find your children. It has caused the women to have breakdowns, to have mental health disorders. But they have actually been labelled as schizophrenic, psychotic, when that really isn't the truth of what's happening for them (Susan Pinckham, NSW Aboriginal Women's Legal Resource Centre, evidence 739).

The Mental Illness Inquiry conducted by HREOC in the early 1990s also noted that mental health services are designed for non-Indigenous people and fail to adapt to Aboriginal needs and beliefs. Indigenous people are significantly more likely than other Australians to live in rural and remote areas, yet these are the areas worst-served by mental health services (Human Rights and Equal Opportunity Commission 1993 chapter 23).

Research in the NT in 1995-96 revealed the nature of the 'second class' treatment experienced by Aboriginal people.

Aboriginal people are less likely to have contact with mental health services prior to their admission ... on admission, Aboriginal people's social and personal history are unlikely to be documented. Somatic treatment only is offered, and little consideration is given to cultural issues, and ... Aboriginal mental health consumers and their families are rarely given information about their mental illness, nor is counselling or psychotherapy (ever) offered (Adams 1996 page 1 citing research by Nagel and Mills).

In Queensland Indigenous people are more than twice as likely to use in-patient services for mental illness (6.4% of inpatients in psychiatric hospitals compared with 2.5% of the population in mid-1995, Mental Health Policy Statement 1996 page 10). This indicates both greater need and less access to preventive programs and community-based care. Also indicative of proportionately greater yet unmet need is the youth suicide rate among Indigenous Queenslanders: more than twice the State average for 15 to 20 year olds (Mental Health Policy Statement 1996 page 11). The Queensland Mental Health Policy Statement suggests that the 'stigma associated with mental illness is very high in [Indigenous] communities' potentially 'prevent[ing] people from seeking early treatment, and often result[ing] in treatment being sought only once an acute or crisis situation has developed' (page 11). Other factors are the cultural inappropriateness of most mental health services for Indigenous people and the almost total absence of community-based preventive programs in Queensland.

South Australian data also reveal high usage by Indigenous people of in-patient services (equivalent to or slightly higher than non-Indigenous rates of use) (SA Government final submission page 48).

To some extent adequate service provision has been hindered by a lack of data on the extent of mental health and emotional problems among Indigenous people. The Inquiry applauds the Commonwealth's intention to remedy the lack of data (submission page 13). However government health departments should recognise that because of their greater exposure to causal factors Indigenous people are more likely than others to experience mental and emotional ill-health. In addition discriminatory treatment such as that revealed by the Northern Territory research cited above cannot be excused.

Having reviewed the Australian literature the authors of the National Consultancy report on Indigenous mental health, Ways Forward, concluded that 'available data indicates significant mental health problems affect at least 30% of the [Indigenous] community and McKendrick's study using systematic measures indicates there is likely to be an even higher level for some groups' (Swan and Raphael 1995 page 36).

It is not possible to quantify the need accurately, as prevalence rates have not been researched. However, the proportion of people who experience severe and recurrent emotional distress or disorder is likely to be considerable (Sydney Aboriginal Mental Health Unit submission 650 page 3).

In light of these findings the Inquiry considers that the needs are first for the provision of targeted services for Indigenous people and second for additional measures to enhance their access to mainstream services.

Existing services

Commonwealth funding

The Commonwealth does not directly provide mental health services. The Commonwealth funds Indigenous medical and health services ($83.3 million in 1996-97) and substance misuse services ($16.8 million in 1996-97) (Commonwealth Government submission page 9). In October 1996 the Minister for Health, Michael Wooldridge, announced a federal commitment of almost $20 million over four years commencing 1996-97 specifically for Indigenous mental health initiatives. The strategy, or 'Action Plan', is based largely on the Ways Forward report.

The Action Plan aims to enhance the cultural appropriateness of mainstream services at the same time as bolstering the capacity of Indigenous primary health care services to meet mental health needs. Families and young people are targeted. For example there are initiatives to reduce youth suicide and strengthening families is a strategy for this.

The need for trauma and grief counselling is recognised. The Action Plan seeks to ensure 'all staff in community controlled health services [will] be trained to handle trauma and loss events while some workers would receive additional training to cover counselling for families and individuals'.

Community-based Indigenous health services are directly funded by the Commonwealth Department of Health and Family Services. They are described below where information is available to provide an overview of the services available in each State.

New South Wales

The NSW Aboriginal Health Strategy is 'in development' and there are plans to employ a number of Aboriginal Mental Health Workers (NSW Government submission page 106). In evidence the Inquiry was told that nine workers would be employed and in training by July 1996 (Maria Williams, Acting Director, Aboriginal Health Unit, evidence).

The Aboriginal Health Branch consulted Link-Up (NSW) in its development of specific policy and programs to respond to 'the Inquiry needs', which we take to mean Indigenous witnesses' needs for follow-up counselling after giving evidence (NSW Government submission pages 106-7). In this process Link-Up observed a general commitment to Indigenous mental health and planning for 'significant improvement' (Link-Up (NSW) submission 186 page 159). The proposed development of responses to the Inquiry witnesses' needs did not eventuate.

One recent NSW initiative is the Central Sydney Aboriginal Mental Health Unit. This service was established in 1995 as a joint project of the Redfern Aboriginal Medical Service, the Aboriginal Health and Resources Co-operative and NSW Health's Central Sydney Area Mental Health Directorate. The Area Clinical Director Professor Marie Bashir and Unit Co-ordinator Sister Robyn Shields have a staff of two (a clinical nurse specialist and a psychiatrist) with two hospital-based psychiatrists also designated. The Unit accepts referrals of Koori patients from a range of sources including prisons, the Aboriginal Medical Service and the Aboriginal Legal Service. Clinics are conducted at the Aboriginal Medical Service and at the State's psychiatric hospital (Rozelle).

In South Sydney a preventive home visiting program for new parents was initiated late in 1996 by the National Association for Prevention of Child Abuse and Neglect (NAPCAN) and the Lions Club. There is a significant Koori population in this area. The Director of the NSW Department of Aboriginal Affairs is represented on the project's Professional Advisory Body and it has the support of the Murawina [Koori] Children's Centre in Redfern. The aim of home visits will be to enhance parents' confidence and self-esteem and to assist them to access local services.

Victoria

The Victorian Government supports the Statewide Aboriginal Mental Health Network established in 1987 by the Victorian Aboriginal Health Service (interim submission page 78). This network is a collaboration between the Aboriginal Health Service and the Government's North-East Metropolitan Psychiatric Services with most staff currently employed by the latter. In addition to a Consultant Director there are two medical officers, two psychiatric service officers and two Aboriginal mental health and liaison workers (the latter based at the Aboriginal Health Service). From the beginning of 1995 the Aboriginal Health Service has been funded to employ a psychiatric nurse directly (Dr Ian Anderson evidence 261). The network primarily responds to Aboriginal people with serious mental illness (Victorian Government interim submission page 77). In-patient needs are met by five designated hospital beds in the north-east metropolitan region. Out-patient services are provided at the Aboriginal Health Service.

Another two Aboriginal mental health workers are employed by other mental health services, giving a total of four for the State (Victorian Government interim submission page 78).

The Koori Kids Mental Health Network is also based at the Aboriginal Health Service. This Network enables the Service to refer children and young people to a roster of psychiatrists and other mental health professionals.

We are able to meet with, assess and work with Koori families at their own Aboriginal Health Service and to facilitate more culturally responsive services in the otherwise intimidating and daunting hospitals and clinics. To many Koories of course these represent the white man's State [and] the removal of their children - their parents, themselves, from family (Dr Campbell Paul submission 768 page 7).

The Victorian Aboriginal Health Service suggested in evidence to the Inquiry that funding for Indigenous mental health services is higher per capita in Victoria than elsewhere in Australia. Nevertheless services are still limited to crisis counselling. Long-term therapy cannot be provided, preventive work with families and communities is not possible and funding does not take into account 'complex presentations' which typically involve physical ill-health, emotional and psychological problems and drug or alcohol abuse (Dr Ian Anderson evidence 261).

The current health funding model is felt to ignore the special needs of Indigenous people, especially in trusting and feeling comfortable with a non-Indigenous health professional. While there may be a budget for the professional, there is rarely funding for an Aboriginal worker to work alongside that professional (Dr Ian Anderson evidence 261).

Queensland

Indigenous people were recognised as a priority group in the Queensland Mental Health Policy (1993) and Plan (1994). Queensland produced a Mental Health Policy Statement for Indigenous people in mid-1996. Of most significance is the proposed shift away from a sole focus on serious mental illness. From now on there should be a dual focus extending also to 'broad social and cultural mental health problems such as widespread depression, anxiety and substance abuse' (Mental Health Policy Statement 1996 page 3).

In Queensland there are three designated government Indigenous mental health professionals (commencing 1996-97). There is one full-time position located in each of the Cairns and Brisbane offices of Queensland Health and an Aboriginal mental health worker is based at the State's psychiatric hospital (John Oxley). In 1995 Queensland reported difficulty in meeting Indigenous demand for mental health services because of the difficulty of 'recruiting specialised staff to work in rural and remote areas' (1994 Progress Report to the RCIADIC page 172). Plans to fund regional Indigenous mental health workers have been foiled for this reason and because trained Indigenous personnel are not available.

To address the latter problem the Cape York Peninsula and Torres Strait Islands district mental health service was funded in 1995-96 to train local Indigenous health workers. Yet even this service experienced difficulty attracting staff with six of the 15.5 positions still vacant at the end of that financial year (Queensland Government final submission, Attachment 16).

Currently, only a small number of Aboriginal and Torres Strait Islander community organisations are funded by Queensland Health to provide mental health services. These organisations have links with specialist mental health services and have been funded predominantly to assist people with mental illness, although some also address cultural and social mental health issues (Mental Health Policy Statement 1996 page 13).

The Commonwealth funds Queensland Indigenous organisations under the National Mental Health Strategy to a total of $213,000 in 1996-97. This funding will cut out in 1998 when the Strategy comes to an end. The 1996 Queensland Mental Health Policy Statement reveals no plans for the State either to take over that funding commitment or to extend mental health funding to more Indigenous community-controlled organisations.

A gathering of Queensland Indigenous community members in November 1995 considered the issues of grief, oppression and mental health.

... participants considered existing mainstream mental health services actually exacerbate the problems of the indigenous community. These mental health services are culturally inappropriate, largely staffed by personnel who have little or no awareness of indigenous culture and sensitivities, and who, for the most part, appear uninterested in developing awareness within that area (Qawanji Ngurrku Jawiyabba 1995 page 2).

South Australia

In response to the National Mental Health Policy South Australia began a process of amalgamating mental health and general health service delivery. Since 1992 the number of specialist non-Indigenous community mental health workers in Adelaide has been increased from 70 to 230. Another 20 are now based in country areas. However there are only three specialist Aboriginal mental health workers, at Port Lincoln, Port Augusta and Adelaide. There is no State policy for mental health services specifically for Aboriginal people (SA Government final submission pages 49- 50).

As in other States and Territories, South Australian mental health services have concentrated to date on serious mental illness. The Government therefore identified relevant service deficiencies.

It is possible that many Aboriginal people experiencing mental illness arising from or connected with separations will not be best assisted by these services. It is likely a possible resource deficiency exists within the arenas of:

• community health mental health services
• private sector eg options such as narrative therapy or alternative healing
• aboriginal mental health services ...
• non-government counselling and support services including both generic and primarily mental health focussed models (SA Government final submission page 53).

Post-traumatic stress is not catered for (page 53). The South Australian Aboriginal Child Care Agency submitted that there are 'inadequate resources' for mental health services in the State.

ACCA field workers constantly witness the need for individual and family counselling. However, within South Australia there are inadequate resources to assist with the cumulative trauma and grief that Aboriginal people suffer. It is more than just a matter of financial resources. Appropriate models of counselling and support need to be developed to assist Aboriginal people in healing. Flexible and accessible counselling programs need to be made available and support given to Aboriginal people undertaking the process of healing (submission 347 page 18).

The Inquiry was told that South Australian mental health services are beginning to develop partnerships with Aboriginal services along the lines of those in Victoria (SA Government final submission pages 54-55).

Country services are likely to remain poor. Consultant psychiatrists refuse to work in rural areas although the use of teleconferencing both to support Aboriginal health workers and as a tool for diagnosis may overcome this difficulty to some extent (Dr David Rathman, Department of State Aboriginal Affairs, evidence). Pitjantjatjara people living in South Australia have to rely on a psychiatric nurse based in the Northern Territory.

This sole position follows up people with diagnosed major mental illness, who have been discharged from Alice Springs hospital. The nurse will cross the borders as required if clients are moving between States, but the N.T. clients have priority for a limited service (Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women's Council submission 676 page 22).

Western Australia

The Aboriginal Health Division of the WA Health Department has ambitious plans to provide appropriate and accessible mental health services across the State (Marion Kickett evidence). At present however only two Indigenous mental health 'programs' are funded and both are located in Aboriginal Medical Services (Tracey Pratt, Aboriginal Health Division, Health Department, evidence). As there are now 13 Aboriginal Medical Services in WA, with an additional four planned, there is ample scope for this funding to be expanded.

The Yorgum Aboriginal Family Counselling Service in Perth was established in 1994 with World Vision funding. The service works with an average of 12 individuals, four families and five groups each week, attempting to cover the gamut of issues from grief and loss, Aboriginal identity and relationships to family violence, sexual assault and racism victimisation. The counsellors are all Aboriginal women. Since funding supports only the co-ordinator's position, Yorgum charges a fee for its services of an amount negotiated with each client.

The State Health Department itself employs some senior Aboriginal people as community liaison workers (not trained as health workers) to assist community members to access regional offices of the Health Department.

Between 27 and 35 Aboriginal patients spend time each month as in-patients of the State's psychiatric hospital (Graylands). The majority of these patients are from rural and remote areas, predominantly the north-west. In evidence to the Inquiry the Government's Aboriginal Health Division noted that the treatment approach at Graylands is not 'culturally appropriate' and that many patients simply should not be in this hospital.

It is just that there are no other institutions set up to be able to deal with these people effectively and people just seem to think that locking them away is the way to deal with them, and it is not (Marion Kickett evidence).

In 1994 an Aboriginal Mental Health Service was established at Graylands. It was recently relaunched as the Aboriginal Psychiatric Service. This Service provides in-patient support, operates a cultural activities centre at the Hospital and aims to provide support to patients and their families on discharge. Staff will accept referrals. For example they are available to visit prisoners in need of support for mental health related issues.

An Aboriginal organisation has recently won a contract to provide cross-cultural training for the health industry, including both government and non-government services (Marion Kickett evidence). The Centre for Aboriginal Studies at Curtin University in Perth offers health worker training to Indigenous people. The program was first offered in 1993. Most students are employed in the health field and take their qualification on a 'block-release' basis (four 2-week intensive teaching blocks each year). Qualifications offered are a Certificate in Aboriginal Health (1 year), an Associate Degree in Aboriginal Health (2 years) and a Bachelor of Applied Science in Indigenous Community Health (3 years). Degree students can specialise in counselling and mental health.

Northern Territory

The Inquiry is grateful to the NT Government for the detailed material supplied on this subject. Although its Indigenous population is similar to that of WA and well under those of Queensland and NSW, the Territory has committed considerably greater resources to the provision of mental health services and shown considerable innovation. Sadly resources remain insufficient and there is evidence of funding reductions in recent years.

Funding applications by the Danila Dilba Aboriginal Medical Service in Darwin to establish a counselling service have been repeatedly rejected.

Since the establishment of Danila Dilba it has always been clear that we needed our own counselling service. We began to make submissions for funds for such a service to both the NT government and to the Federal government. We saw the counselling service as part of what we called the Family Support Unit which also included men's health and allied services including counselling to families in crisis and beyond. All without success ...

The NT government provided some project funds to Danila Dilba to have a domestic violence counsellor on staff. Although the counselling was funded from this project, she was actually providing a general counselling service and did not deal exclusively with domestic violence. This counsellor was extremely busy and we built up the expectation in our community that we could provide this service. The NT government chose after twelve months not to fund this position any longer and we lost the counsellor and placed many clients in limbo (submission 537 pages 1 and 2).

Late in 1996 the NT Minister for Health Services promised $70,000 over two years to Danila Dilba to establish a counselling service specifically for people affected by past policies of forcible removal. In 1995-96 three other Aboriginal organisations also received mental health grants of between $21,000 and $26,000 each. At the same time the Government itself employs ten Aboriginal mental health workers, two of whom are contracted to a community based health association (NT Government supplementary information, exhibit 20 page 6).

A review of the innovative East Arnhem Mental Health Teams dated November 1995 strongly supports the expectation that there is a substantial demand for culturally-appropriate mental health services which only becomes fully apparent when such a service is provided. The East Arnhem project was overwhelmed by the demand for its services once the service providers approached communities appropriately and the Indigenous people came to recognise the services offered as relevant to their needs. This experience is graphically captured in the following anecdote from a community health nurse.

I was the first Mental Health person that had ever visited this community. There was only one person from this area known to be suffering from any form of mental illness. The day was spent sitting with this small group of people listening to and telling stories about people with mental health problems. At the end of my visit one of the elders said 'so you are the man who works with sadness problems'. While listening to my stories the elders had been conducting their own community needs analysis and then told me their priorities. In the 10 months since that visit there have been five other referrals from that community (Mcleod 1995 page 11).

Yet resources for the East Arnhem project far from growing in response to this increased demand have been reduced. The experience of burgeoning demand in response to the provision of appropriate services was confirmed by Danila Dilba.

When we began [in 1991], we were seeing 300 people per month, now we are seeing approximately 1,100 per month to 1,400 per month. The longer our Service is in operation the more needs are demanded by our community and identified by us (submission 537 page 1).

Tasmania

The Tasmanian Government informed the Inquiry that Indigenous mental health had not been researched for its submission or evidence. The Tasmanian Aboriginal Centre advised that '[t]here are no counselling services available to deal specifically with Aboriginal families affected by separation' (submission 325 page 8).

ACT

The ACT's mental health services strategic plan dated December 1993 identified 'Aboriginals' as a special needs group but made no mention of culturally appropriate service development or delivery (ACT Health 1993 page 29). However in 1996 a review of Indigenous people's needs and an evaluation of services was undertaken (ACT Government interim submission page 23).

The Inquiry was told of a training program for Aboriginal mental health workers at the Queanbeyan Mental Health Service but no details were provided (ACT Government interim submission page 28).

Evaluation government objectives

All Australian governments have endorsed the 1990 National Aboriginal Health Strategy and have affirmed their endorsement by approving Recommendation 271 of the Royal Commission into Aboriginal Deaths in Custody which regards implementation of the Strategy as 'crucial'. Pursuant to the Strategy the Commonwealth commissioned a national consultancy report. Its submission to the Inquiry adopted the report Ways Forward as a baseline document to be used when planning and delivering services, developing policy, developing education and training programs and developing data collection and research priorities' (Commonwealth Government submission page 14).

The Commonwealth relies on the report's principles in negotiating Commonwealth-State funding agreements on Indigenous health (Commonwealth Government submission page 15). The Queensland Government advised that the report 'was used as a guide for development of the Queensland Mental Health Policy Statement for Aboriginal and Torres Strait Islander People' (final submission page 16). The NSW Government advised that 'NSW Health supports the aims and recommendations of Ways Forward and has incorporated them in the draft NSW Aboriginal Mental Health Policy/Strategy document' (final submission page 16). The Inquiry endorses Ways Forward as setting out the broad objectives for all governments in the area of Indigenous mental health.

The Commonwealth Government identified three guiding principles (submission page 14). Indigenous mental health services should,

• be based on a mental health promotion and prevention model,
• emphasise the primacy of Indigenous empowerment and self-determination, and
• adopt an holistic approach.

Health promotion and prevention model

The desirability of this model is indicated by the prevalence of psychological distress and psychiatric problems affecting Indigenous people.

Any approach to Aboriginal mental health based simply on direct treatment programs, is unlikely to impact significantly on outcomes for Aboriginal communities (Swan and Raphael Ways Forward 1995 page 85).

Strategies should include Indigenous community education about psychological distress and development of prevention programs for those at risk. The humanitarian benefit of prevention and early intervention is obvious. Economic benefits can also be demonstrated. The East Arnhem early intervention strategy achieved a reduction in emergency evacuations of petrol sniffers to hospital in Darwin from 43 in 1991 to just five in 1993 at a saving per patient of ovef $5,000 for an air evacuation and over $75,000 for in-patient treatment for lead toxicity (Mcleod 1995 pages 7 and 9). To date however mental health interventions for Indigenous people have significantly clustered towards acute and crisis intervention and away from community health promotion and prevention strategies.

Trauma and grief 'were identified as amongst the most serious, distressing and disabling issues faced by Aboriginal people both as a cause of mental health problems and as major problems in their own right' (Swan and Raphael Ways Forward 1995 page 3). Only the most recent Commonwealth initiative addresses this issue.

Ways Forward proposed that priority be accorded to violence and destructive behaviours (page 5). There is no evidence of any mental health project acknowledging that these issues should be incorporated within the definition of mental health (with the obvious exception of self-destructive behaviours) much less of recent initiatives according them priority. These matters are, however, the focus of the NSW Aboriginal Family Health Strategy launched in 1996.

Indigenous empowerment and self-determination

The Ways Forward report stated,

It is essential in terms of recognition of the needs and wishes of Aboriginal people that the implementation of policy is managed, coordinated, monitored and evaluated by Aboriginal people and organisations (page 21).

Indeed 'self-determination is central to Aboriginal people's well-being' and 'denial of this right contributes significantly to mental ill-health' (page 21). The 1990 National Aboriginal Health Strategy also identified self-determination in health care as essential (Swan and Raphael Ways Forward 1995 page 21).

Most States and the Northern Territory now support Aboriginal medical and health services. Tasmania, South Australia and the ACT are notable exceptions. A preponderance of resources, including 'human resources' such as Aboriginal mental health workers, are still controlled by government health departments. This preponderance in part reflects the fact that most mental health resources are devoted to the care of the mentally ill rather than to health promotion and the prevention of mental illness.

Holistic approach

A holistic approach is one which permits mental health issues to be addressed in the 'general health sector'. Mental health care must be part of primary health care as well as reflecting Aboriginal values and approaches to mental and general well-being (Swan and Raphael Ways Forward 1995 page 26).

This approach requires, for example, that Indigenous medical and health services be equipped to deal with mental health issues and that Indigenous general health workers be trained to recognise and deal with mental health problems and mental disorders (page 26).

The general reluctance to pursue this strategy wholeheartedly seems to stem from the continued emphasis on more acute care. A preventive focus would be more conducive to facilitating a holistic approach. Similarly the more mental health resources are placed at the disposal of Indigenous organisations implementing self-determination, the more their values and needs can be incorporated in the overall approach to Indigenous mental well-being.

Evaluation Inquiry criteria

The Inquiry's evaluation criteria are largely consistent with the objectives for Indigenous mental health provision set out in Ways Forward.

Self-determination

As noted above, the bulk of mental health resources continue to be controlled by governments and non-Indigenous non-government agencies. If effective Indigenous-controlled primary and preventive programs were widely available it might well be efficient and appropriate for secondary and tertiary services, for a much smaller minority of Indigenous patients, to remain under government control. It would still be essential for the government to work in partnership with local or regional Indigenous community organisations in the provision of acute care.

Ways Forward proposed the establishment of a National Aboriginal Mental Health Advisory Committee to 'oversee, coordinate and monitor' national policy and planning (page 23). Consultations in the Northern Territory came to a similar conclusion.

The Aboriginal Reference Groups or a Consultative Network of prominent Aboriginal people must be responsible for the provision of high level advice and direction to the Minister ... Territory Health Service must make their staff accountable to Aboriginal people and communities ... (Adams 1996 pages vi and vii).

The Commonwealth Government advised the Inquiry that an Aboriginal and Torres Strait Islander Health Council was established in 1996 at the federal level (submission page 10).

Non-discrimination

The National Aboriginal Health Strategy and the Indigenous mental health component of the National Mental Health Policy are responses to the very significant discrimination experienced by Indigenous people in using or needing to use mainstream mental health services. Therefore there is reason to be optimistic that in the not-too-distant future discrimination in access to mental health care will be significantly diminished.

A key feature of Indigenous mental health care provision is the discrepancy between what is available in urban areas and what is provided in rural and remote communities.

Aboriginal mental health has been neglected by our profession [psychiatry]. In the tumult of political and social change the voices of young Aborigines, particularly in remote Australia, are unheard and their needs unmet (Hunter 1995 page 382).

The Inquiry therefore commends the aspirations in the Queensland Mental Health Policy Statement for Indigenous people (1996).

The Policy aims to bring mental health services closer to where Aboriginal and Torres Strait Islander people live; to ensure that Aboriginal and Torres Strait Islander people are employed in specialist mental health services and in primary health care services to address the two areas of need in mental health; to ensure that cultural awareness training is provided to mental health services staff by Aboriginal and Torres Strait Islander people; and that cultural awareness training is included in curricula of relevant tertiary education courses (page 3).

Cultural renewal

The predominant health model informing most health service provision to Indigenous people remains a Western model. Where traditional culture remains strong, insistence on the Western approach could cause significant problems including exacerbation of ill-health. Strategies within the Indigenous community for promoting well-being are undermined.

Bad Health is not being connected to your spiritual being. This indicates all those important parts of your life are not connected, being damaged by different forces not of our control or doing. For example, people taken away from their families and country, and made to live in another environment like missions or homes.

[Service delivery must recognise] that introduced influences such as colonisation, government policies, Whiteman's invasion, alcohol, Stolen Generation, oppression, Christianity, and destruction of Aboriginal societies and cultures, genocide, institutional racism and poverty has contributed to Aboriginal mental health.

Territory Health Service [must] recognise and acknowledge the consequences ... [and] make it compulsory for all health personnel to attend Aboriginal developed and delivered cross-culture awareness programs and abide by Aboriginal cultural protocols developed in partnership with Aboriginal people (Adams 1996 page 48).

Cross-cultural training programs are slowly being introduced in the health sector. While necessary, this training is not sufficient to ensure full respect for and incorporation of Aboriginal values and concepts of health and well-being. Devolution of service provision to Indigenous-controlled organisations will best secure this objective. These organisations should be flexibly funded to utilise community healing expertise and to incorporate a model of health and well-being dictated by the community being served.

Coherent policy base

Ways Forward presents all Australian governments with a comprehensive and coherent policy base from which to develop programs and to deliver adequate, appropriate and effective services. Governments are still only in the process of developing their Indigenous mental health policies or planning for implementation. The position described in Tasmania therefore prevails more generally.

The current social welfare policies within Tasmania merely seek to patch up identified problems. There is no long term social policy in place. Government response is therefore ad hoc (Tasmanian Aboriginal Centre submission 325 page 8).

Adequate resources

The Inquiry was told that despite the adoption of the National Aboriginal Health Strategy in 1990 mental health resources are still grossly inadequate in all jurisdictions. A comparison might be made between existing Indigenous mental health provision in Queensland Health and the need identified by the Mental Health Branch. In October 1996 there were three dedicated professional positions in the State. The Branch identified an immediate need for another nine (a 300% increase) (Queensland Government final submission page 15).

Services to deal with loss, grief and depression are virtually non-existent. Historically the emphasis has been on major mental illnesses and acute care. The extent of emotional problems caused by the forcible removal policies has only recently been revealed and has yet to be fully acknowledged. Even in the relatively well-resourced Northern Territory 'there are not enough psychiatric nurses or mental health professionals visiting Aboriginal communities' (Adams 1996 page 10).

There are no support facilities in remote communities for victims of family violence. When an event like family violence or rape occurs, police interview notes are taken or medical examination is completed and the victim is sent home. There is no counselling or debriefing (primary, secondary or tertiary) conducted either for the victim or the family (Adams 1996 page 43).

These issues [where removal has led to an inability to nurture children who in turn develop behavioural disturbances] often require intensive resources [including] lots of individual therapy and also family therapy. That's one of the key areas where there's a real lack of good services at a primary health care level (Dr Ian Anderson, Victorian Aboriginal Health Service, evidence 260).

Continuing emotional distress as a result of the removal policies receives insufficient attention.

There are very limited counselling or specific services available to Aboriginal and Torres Strait Islander people directed to assisting families and individuals who have been affected by the separation under compulsion, duress or undue influence of any Aboriginal or Torres Strait Islander children from their families. General mental health services, i.e. mainstream, have been described as not being aware of or responsive to Aboriginal people's mental health issues generally and to the issues of trauma and grief in particular (Professor Beverley Raphael submission 658 page 3). What this means for Link-Up clients and for separated people in general who are dealing with long term and profound distress as a result of separations, is that there are very few services available to meet their counselling and specialised therapeutic needs (Link-Up (NSW) submission 186 page 159).

Recommendations

Our recommendations are underpinned by the recognition that a substantial injection of funding is needed to address the emotional and well-being needs of Indigenous people affected by forcible removal. In addition it is clear that these needs must be treated as unique because of their causes and because of the family and socio-economic contexts in which they are now experienced.

By funding rehabilitation services for survivors of torture the Commonwealth and States have already recognised the need for specialist services, in this case particularly for refugees and other immigrant torture and trauma survivors, to meet unique needs. There is a torture and trauma rehabilitation service in each State and Territory with substantial joint Commonwealth-State funding and large professional and bilingual staffing. For example, the Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS) in NSW receives $1.3 million annually to deal with a caseload of approximately 400 clients each year. These services meet a distinctive mental health need. Indigenous mental healt needs are also distinctive and require similar specialist responses.

Data collection

Before services addressing the range of needs arising from the forcible removal policies can be planned and implemented, basic information is needed on what and where those needs are. Indigenous people, specifically organisations already confronted by aspects of the traumas and other issues arising, need to be involved as partners in the collection of that information. These organisations include family tracing and reunion services, Aboriginal and Islander Child Care Agencies and medical and health services.

The [1993 National Aboriginal Mental Health] Conference demanded that research into all aspects of Aboriginal and Torres Strait Islander communities, be undertaken only within Aboriginal and Torres Strait Islander community designed guidelines, including community participation and only with full consent of the particular community, with whom research is to be undertaken (Swan and Raphael 1994 page 35).

The Royal Commission into Aboriginal Deaths in Custody recognised the importance of Indigenous participation in research design and recommended that 'Aboriginal people be involved in each stage of the development of Aboriginal health statistics' (Recommendation 271(a)). Further, Recommendation 48 provides,

That when social indicators are to be used to monitor and/or evaluate policies and programs concerning Aboriginal people, the informed views of Aboriginal people should be incorporated into the development, interpretation and use of the indicators, to ensure that they adequately reflect Aboriginal perceptions and aspirations. In particular, it is recommended that authorities considering information gathering activities concerning Aboriginal people should consult with ATSIC and other Aboriginal organizations, such as NAIHO or NAILSS, as to the project.

A simple count of people presenting with mental illnesses and disorders is insufficient. Emotional problems and issues relating to well-being are much broader than established mental illnesses and disorders that are at the extreme of the problems needing to be covered. Moreover the chances of misdiagnosis of Indigenous patients is significant. Governments which have adopted the national consultancy report Ways Forward already recognise these issues.

Indigenous well-being models

For Indigenous people 'health does not just mean the physical well-being of the individual but refers to the social, emotional and cultural well-being of the whole community' (Swan and Raphael Ways Forward 1995 page 1).

Aboriginal people have a spiritual contact with life as part of being in touch with the land, trees, air and earth. Aboriginal people feel better when they are involved in cultural activities. Those people who stay in the bush and participate in cultural activities seem to be more healthier, only the old people become sick through diabetes and high blood pressure ... However, not all Aboriginal mental health consumers are able to partake in cultural activities. This could be caused through the lack of transport, location, ignorance or reliance on the medical model. Aboriginal Mental Health Consultants and Aboriginal Health Consultants must include cultural activities as part of their employment in primary health care (Adams 1996 page 30).

Traditional Aboriginal culture like many others does not conceive of illness, mental or otherwise, as a distinct medical entity. Rather there is a more holistic conception of life in which individual wellbeing is intimately associated with collective wellbeing. It involves harmony in social relationships, in spiritual relationships and in the fundamental relationship with the land and other aspects of the physical environment. In these terms diagnosis of an individual illness is meaningless or even counterproductive if it isolates the individual from these relationships (Sydney Aboriginal Mental Health Unit evidence 650).

Thus it has been proposed that,

[There is a] need to develop services and programs according to Aboriginal terms of reference, concepts, values, beliefs, ways of working, priorities that recognise the diversity of Aboriginal culture ... When Aboriginal and non-Aboriginal people are employed to deliver Mental Health Education Programs they must recognise and respect local Aboriginal cultures and people. Aboriginal people must be included and employed in the program development, management, processes, implementation, documentation, evaluation, funding and delivery (Adams 1996 page 6).

The Queensland Mental Health Policy Statement for Indigenous people adopted mid-1996 has recognised the issue.

Mental health is viewed by Aboriginal and Torres Strait Islander people as a broad concept. It includes the social, emotional, cultural, physical and mental well being of the individual and the whole community, and is based on current, historical and spiritual values.

Features of mental disorders may differ to those in the non-indigenous population, leading to the possibility of misdiagnosis. Mental health issues for Aboriginal and Torres Strait Islanders must therefore be understood beyond those conditions which are dealt with in a traditional Western clinical context, in keeping with the culturally defined concept of health ... (pages 3 and 10).

Link-Up (NSW) called for 'culturally appropriate definitions of mental health'.

Understandings of mental health are culturally specific. Aboriginal understandings of mental distress may be different from those in European Mental Health Diagnostic Manuals. In developing community-based recovery strategies, it is essential to develop culturally appropriate Aboriginal definitions of mental health and mental illness (submission 186).

The Inquiry was advised that culturally-appropriate healing models do exist and are being used by Indigenous services and projects. They include traditional healing, art therapy and narrative therapy. Colleen Brown, NSW Aboriginal Health Educator, described her use of art therapy in which young people express problems and hurt through painting (evidence 842). Relationships Australia (formerly the Marriage Guidance Council) described the narrative therapy model devised by Michael White and utilised with Nunga people in South Australia.

It is a model that takes into account injustice, responsibility and oral history. Michael sees that our lives are a story that provides context for our experiences. He sees that society and the individual process this story and give it an interpretation. This interpretation then effects what we do and the steps that we take in life. Michael's counselling listens to the story that has shaped a person's life. The theory aims to give an alternate story to 'how life may be' by talking through alternatives. Michael's work also addresses mapping the effects of the problem. It is here that he looks at the effects of the problem in light of people's lives and their relationships. It seems that Michael White is also interested in aspects such as: . naming injustice . healing through traditional means . caring and sharing . remembering . being listened to (submission 685 page 7).

Further development and evaluation of these and other models, particularly as applicable to grief and trauma and the inter-generational effects of the forcible removal policies, are needed. There must be opportunities for documentation and sharing of innovations and lessons across Australia.

... Aboriginal people have been working in this area and there is a valuable amount of information and techniques available. This information needs to be brought to an awareness, documented, and distributed to National Aboriginal Australia. Thus creating a cultural sensitive counselling programme that can be added to continuously (report from Joyleen Koolmatrie, Sept 1996).

At the same time it must be appreciated that,

Traditional healing practices are diverse and specific to individual communities and family groups. They may include traditional song and dance, food and medicine. In some communities the use of traditional healing is predominant, being regarded as essential for cultural and spiritual well being (Queensland Mental Health Policy Statement 1996 page 12).

Indigenous healing may also be dependent on particular locations on traditional lands. Dr Jane McKendrick of the Victorian Aboriginal Mental Health Network told the Inquiry,

... it has been my experience with some Aboriginal people who have been taken away from their families in childhood and who have had severe mental health problems in adulthood have really benefited from going home, spending time on their traditional land with their elders and extended family. The healing process might take a few years, but that is by far the best way to do that (evidence 310).

Submissions to the Inquiry made clear that primary 'well-being' services need to be controlled and delivered by Indigenous people.

If you did not have the mental health worker there who can communicate with the patient in language the patient understands, you know, talk in terms of things important to the patient and the patient knows are important to the health worker - it helps to settle things down. But if you do not have that sort of trained person present there can be disastrous consequences. It could even lead to either unnecessary hospitalisation or in the worst case a successful suicide (Dr Jane McKendrick, Victorian Aboriginal Mental Health Network, evidence 310). I sought counselling to try and help me overcome a lot of the feelings I carry with me from my childhood, but it doesn't seem to really help. The counselling I received has not been from people that know much about Aboriginal culture or what we went through at the mission (quoted by ALSWA submission 127 on page 200). Non-Aboriginal nurses have a lot of difficulty establishing rapport and trust with Koori mothers precisely because it was often nurses [in Victoria] who were most likely to be associated with the removal of Aboriginal children (Dr Ian Anderson, Victorian Aboriginal Health Service, evidence 261). The most important thing is that some sort of access or system is established where there is a high degree of trust. [It] would have to be very strongly focused around an Aboriginal community network or an Aboriginal community counselling service because there may be some very particular ways these issues should be addressed by Aboriginal people in which [non-Indigenous professionals] should at best have some sort of advisory role or assistance (Dr Nick Kowalenko evidence 740).

The 1996 Stolen Generations National Conference recommended the establishment of 'counselling centres, established and run and staffed by Aboriginal people [as] an essential and urgent part of the rehabilitation component of a reparation package' (submission 754 page 50). A number of Indigenous organisations similarly called for self-determining Indigenous healing centres (Broome and Derby Working Groups submission 518 page 5, Aboriginal Legal Rights Movement submission 484 page 53, Karu Aboriginal and Islander Child Care Agency submission 540 page 34, Western Aboriginal Legal Service (Broken Hill) submission 775).

UN Special Rapporteur van Boven recognised government support of rehabilitation for victims of gross violations of human rights as essential to reparations. Principle 14 provides that,

Rehabilitation shall be provided and will include medical and psychological care as well as legal and social services.

There are very strong and cogent arguments for 'well-being centres' which offer a full range of healing services. This is consistent with the recommendation in Ways Forward for holistic primary health care services.

Commitment to holistic view of health and the cyclical concept of life, death, life, so that mental health programmes should be based in a community setting with no artificial separation of children and elders from people in middle life ... so everything should be under the one umbrella. And also in a primary health care setting because people who are psychologically distressed often have chronic physical problems (Dr Jane McKendrick, Victorian Aboriginal Mental Health Network, evidence 310). Everyone at the [1995 Queensland] Gathering expressed the need for funding for Indigenous Healing Places initiated, established and staffed by our own people with access to other help as is needed and appropriate. These Healing Places are envisaged as places where intervention can happen before, during, and after crises, and provide longer term care also. We must be funded to provide an alternative to the mainstream facilities (Qawanji Ngurrku Jawiyabba 1995 page 4).

This approach was supported by the 1993 National Aboriginal Mental Health Conference which noted that mental health should be seen as part of primary health care and not separate from it and that spiritual life and traditional ways are important to Aboriginal well-being.

The majority of mental health disorders and mental health problems in Aborigines and Torres Strait Islanders do not require dual intervention for specialised secondary services. It is therefore illogical to separate emotional well being issues and therefore mental health services from primary health care (as defined by the NACCHO). A holistic, integrated team approach to well being is required through community controlled health services ... resourced effectively by professionals and through financial resourcing (Swan and Raphael 1994 page 32).

The Conference proposed an immediate allocation of $100 million for comprehensive counselling services in Indigenous community-based organisations simply to tackle immediate issues (Swan and Raphael 1994 page 25). Funding for Indigenous community-based services must empower those services to utilise culturally appropriate healing models and personnel including traditional healers where they are available.

Our traditional healers must be funded to do their work in the community. At the moment their work is not recognised by funding bodies yet their role is essential to the healing of our people - more so than white medicine and white interventions (Qawanji Ngurrku Jawiyabba 1995 page 4).

Staff training

The Royal Commission into Aboriginal Deaths in Custody recognised the importance of training professionals dealing with Indigenous patients about Indigenous history with the expectation that a better and more appropriate service will be provided. Recommendation 154 addressed training of health professionals working in the prison system.

All staff of Prison Medical Services should receive training to ensure that they have an understanding and appreciation of those issues which relate to Aboriginal health, including Aboriginal history, culture and life-style so as to assist them in their dealings with Aboriginal people.

Indigenous people too will need appropriate training to meet the new demands of working within culturally appropriate models of well-being while at the same time liaising with non-Indigenous professionals and services to obtain specialist assistance as needed. The Curtin University, WA, counselling course offers one training model. The course is designed, managed and directed by professional Indigenous staff and takes a holistic approach to mental health (Collard and Garvey 1994).

Parenting and family well-being

The effects of forcible removal are far-reaching and complex and often compounded in subsequent generations. A focus simply on 'mental health' therefore is inappropriate for two reasons. First, the concept is a western one which does not encompass the Indigenous perspective of social, spiritual and community well-being. Second, healing the effects of forcible removal will require a number of inter-related strategies, only one of which is clearly covered by the term 'mental health'. All the effects of the removal policies need to be addressed including substance misuse, parenting skills deficits, impacts on physical well-being, children's and youths' behavioural disturbances and so on. We can understand all of these under the general rubric of rehabilitation while recognising that the need for rehabilitation will be felt by the people who were removed, their families including their own children and grandchildren and their communities as a whole.

It is imperative that separation, identity issues and their effects on Aboriginal wellbeing are kept in the forefront as Aboriginal Mental Health Services are developed and implemented, and in training Aboriginal Mental Health Liaison Officers (Link-Up (NSW) submission 186 page 159).

A very significant continuing effect of the forcible child removal policies has been the undermining of parenting skills and confidence. Rebuilding these must be a priority. The 1993 National Aboriginal Mental Health Conference recommended that 'culturally appropriate Aboriginal family therapy programs be developed by Aboriginal Legal, Medical and Children's Services' (Swan and Raphael 1994 page 31).

Most communities suggest the need for special programs to support young Aboriginal people and to redevelop parenting skills both in terms of child rearing generally and traditional practices (Raphael et al 1996 page 15).

Submissions to the Inquiry from Indigenous organisations were very supportive of these programs.

That parenting programs be developed and made available for carers who might benefit from such programs. These programs must be provided from appropriate organisations such as Aboriginal Child Care Agencies and must be developed and provided in a culturally appropriate manner ... That preventive family support programs be developed and run from accessible organisations such as Aboriginal Child Care Agencies (SA Aboriginal Child Care Agency submission 347 recommendations 7 and 9). Today there is a massive Koori Parenting crisis, which VACCA [Victorian Aboriginal Child Care Agency] confronts daily with parents in difficulties coping with their children, and in the many manifestations of family violence. VACCA's experienced workers perceive a strong link between children who do not receive adequate nurturing, consistent parenting, especially in their earliest years, and their later violent behaviour in their family settings (Jenny Gerrand submission 578 page 3).

The 1995 report of the WA Taskforce on Families also identified the issue and proposed a similar solution.

... most of the problems faced by Aboriginal people today stem from generations of oppression and have resulted in a lack of trust in the non-Aboriginal society. The Native Welfare Department's practice of taking Aboriginal children from their families to be brought up on missions, still impacts upon Aboriginal people in Western Australia. One of the most important consequences of this practice is the lack of parenting skills due to the fact that thousands of children were denied nurturing, loving and modelling by their parents and extended family. It also caused a major disruption in the transmission of culture and traditional values (page 106).

The Taskforce recommended,

That the Department for Community Development work with members of the Aboriginal community to develop and implement specific and appropriate parenting programs, services and courses designed for Aboriginal parents, recognising the primary role played by grandparents and the extended family in the upbringing of the children (page 106).

In evidence to the Inquiry child and adolescent psychiatrist Dr Brent Waters agreed.

Young people need to have available to them people who can work with them as they deal with whether or not they're going to form families and how they manage the first stages of parenting ... It is very, very important that there are resources available, not only to support these people who are susceptible to passing on a pattern of neglectful and abusive parenting, but who can actually provide concrete advice on what to do. That certainly should come from within the Aboriginal community. A generation which in my experience has a great potential to assist there is the grandparent generation (evidence 532).

In response to the need the Victorian Aboriginal Child Care Agency has proposed the establishment of a Koori Parenting Centre 'to deliver to Koories whose parenting skills need building up, the necessary input so that these parents can achieve their long-term goal of caring for their children, and of becoming self-determining people' (submission 578 page 3). Among other strategies 'VACCA has commenced work on a video and book about culturally-relevant ways of parenting called 'Parenting: Doing it Our Way'. Victorian Koori elders are interviewed about the ways they parented their children (submission 578 page 4).

In making this recommendation we do not intend to further fragment the delivery of needed services. The point was clearly made to the Inquiry that a holistic approach is essential.

Aboriginal health issues can't be isolated. What have we got? We've got alcohol and drug over here, we've got domestic violence centre over here, we've got medical centres over here, diabetes over there. They can't be separated like that. The physical body will heal once we heal our spirit from all of our past pains, traumas and tragedies. We've got to look at the whole thing holistically (Rosemary Wanganeen evidence 256).

The proposed parenting and family well-being centres are likely therefore to be located in existing Aboriginal and Torres Strait Islander medical and health services and/or Aboriginal and Islander Child Care Agencies.

Prisoners

Special attention must be paid to people in custody. Indigenous people are still over-represented in both juvenile and adult detention and are more likely than non-Indigenous people to be returned to prison within a comparatively short time of the completion of a sentence.

... the system that has left us with a legacy of discrimination and disadvantage also pathologises us for feeling angry and abused and imprisons and institutionalises us instead of recognising that our feelings are valid and need to be addressed. Very often our people are imprisoned when the intervention that is indicated is actually medical (Qawanji Ngurrku Jawiyabba 1995 page 3).

The distance of most detention centres and many prisons from Indigenous population centres means isolation for Indigenous prisoners which increases their distress.

Recent reports have highlighted a range of problems for Aboriginal and Torres Strait Islanders with mental disorders or mental distress in custodial correctional centres, linking suicide among young males with untreated mental illness, alcohol abuse, profound despair and demoralisation (Queensland Mental Health Policy Statement 1996 page 14).

Because of repeated incarceration and isolation these people are least able to take advantage of Indigenous mental health services. Even where services are available '[t]here is a problem with lack of continuity of care and appropriate follow-up ... particularly ... when they are transferred throughout the statewide prison network' (Queensland Mental Health Policy Statement 1996 page 14).

An efficient prison mental health service with good consultative links with Indigenous health services and employing Indigenous mental health workers will identify and assist many prisoners with mental illnesses or disorders. Again however a broader preventive approach is needed which directly addresses the emotional distress and despair common to most Indigenous prisoners and their underlying causes. A focus on more psychiatrists, as proposed by the Queensland Mental Health Policy Statement 1996, will ignore this broader spectrum of need.

The Royal Commission into Aboriginal Deaths in Custody appreciated the significance of corrections departments working with Aboriginal and Islander health and medical services. Recommendation 152 provides in part,

That Corrective Services in conjunction with Aboriginal Health Services and such other bodies as may be appropriate should review the provision of health services to Aboriginal prisoners in correctional institutions ... Particular attention should be given to drug and alcohol treatment, rehabilitative and preventative education and counselling programs for Aboriginal prisoners. Such programs should be provided, where possible, by Aboriginal people ... The involvement of Aboriginal Health Services in the provision of general and mental health care to Aboriginal prisoners ...

Carol

[Carol's grandmother was removed to Beagle Bay at the age of 10. She and her husband had 10 children. When her husband was transferred to the Derby leprosarium, all ten children were placed in the Beagle Bay dormitories. Carol's mother was 8 years old when she was removed. Carol was born in Broome in the mid-1950s. When she was three, her mother died leaving four children. Although her grandmother was still alive, Carol and her siblings were removed to the Beagle Bay dormitories. Carol spent the next 14 years there.]

Five generations of my family have been affected by removal of children. Four generations of my family have been removed from their mothers and institutionalised. Three generations of my family have been put into Beagle Bay Mission dormitories. Four generations of my family went without parently love, without mother or father. I myself found it very hard to show any love to my children because I wasn't given that, so was my mother and grandmother.

When I think back on my childhood days - sad, lonely and unloved childhood days - we should have been treated better than we were by the Church. We were mistreated badly. I was abused by the missionaries from all angles - sexual, physical and mental. I am a strong person in myself. I had to be strong, I had no-one to turn to, no-one to guide me through life.

6.30am every morning, straight from bed, we had to kneel and say our morning prayers. 7am we had to go to church for mass. If we didn't we would be punished, like going without a piece of bread for breakfast or get the strap or whipped on our palms. 7.30am we had to thank God before and after our breakfast. 8.30am before and after class we said our prayers. 10am we had to say another prayer before we had our cups of milk and morning tea break. 11am we had catechism taught to us which was part of praying and learning the history of our church. 12pm again we said our prayers before and after our lunch. 1pm we said another prayer before and after class. 5pm we prayed again before and after our supper. 6pm most times we had to go to church for Benediction or rosary. 7pm we would kneel and say the last prayer of the day, which was our night prayers.

We were locked up every night. Also during the day on weekends and public holidays. That was only when we didn't go out on picnics.

7am breakfast - very light which was only sago with milk or most times porridge. 10am morning tea time: one cup of Carnation milk. 12am lunch, very light sometimes one piece of bread covered with lard along with a small piece of boiled meat. We loved it all the same. 5pm supper, very light which was 'bubble-bubbles' which was only flour, sugar and water, and if we were lucky we would have a piece of fruit.

We had nothing else to eat, only if we stole vegetables from the garden. We had two big vegetable gardens. Every vegetable was grown there yet we were never given any. We never had vegetables. Things that we never saw on our meal table yet were sold elsewhere from Beagle Bay Mission. When it was my turn to work in the convent kitchen I saw that all the vegetables that our people grew were on their meal tables.

Everyone would think we were doing the laundries for a big hospital, how many times and how we washed the missionaries' laundry. Every Sunday evening we had to soak the missionaries' laundry. Every Monday morning we washed clothes by hands or scrubbing board. We then had to rinse and put it into the big boilers. Then rinsed, then starched, then rinsed, then squeezed and hung out to dry. We had to iron all the clothes, plus mending and darning.

We made our own clothes for the girls and the boys that were in the dormitory. We never was given footwear, only when and if we were making our first communion, confirmation or crowning of Our Lady. It felt real good to wear shoes and nice dresses for only an hour or so.

We were treated like animals when it came to lollies. We had to dive in the dirt when lollies were thrown to us. The lollies went straight into our mouths from the dirt. We had to, if it was birthday or feast day of the missionaries, wish them a happy day, take our lollies and run, knowing what could happen. We had to sometimes kiss the missionaries on the lips, or touch their penises. I remember clearly on one occasion, I was told to put my hands down his pants to get my lolly.

The nuns taught us that our private parts were forbidden to touch. If we were caught washing our private parts, we would get into trouble from the nuns. I grew up knowing that our private parts were evil, yet missionaries could touch us when they felt like it. That is why when I grew up that I automatically thought when a man wanted sex that I had to give it to him, because that's what, y'know. Sometimes I had sex not for pleasure, but just to please the man.

Even at the dormitory, when we used to complain to the nuns about what the brothers and the priests had done to us, we were told to shut our mouths. That's why they used to always tell me I'm a troublemaker. Those same priests, they're still alive, they're still working down south. Even the nuns are still here in Broome; there's a couple of them still there.

It never happened to me, but I remember the priest ... used to just walk into the dormitory and pick any girl out of the crowd, 'You, come with me', and take them. And I noticed, when those girls used to come back they were very upset. I can't say what really happened there, but 'til this very day, those people don't go to church.

The thing that hurt me the most while growing up is that we were pulled away from our sisters and brothers. My sister's a year younger than I, yet I could not hold her, cry with her, play with her, sleep with her, comfort her when someone hit her, and eat with her. We weren't allowed to be close to our sisters or brothers. The missionaries pulled and kept us apart.

I was taken out of school when I was only 15 years of age by the nuns and placed with the working girls. I had no further education. To leave the mission I had to have two people to sort of say they'd look after me. [Carol lived with an aunt and worked as a domestic for a family in Broome.] I remember being reminded many times about being sent back to Beagle Bay if I did not do my work properly or not listening to the them. I did not want to go back there, so I had no choice but to listen. This is one of many times I felt trapped. I was treated like a slave, always being ordered to do this or do that, serving visitors and being polite to them.

[At 19, Carol gave birth to a son.] I had no-one to guide me through life, no-one to tell me how to be a good mother. A year later I fell pregnant with my second child. My son was only a year old and I kept being reminded by the Welfare and by my so-called family that they'd take my babies away from me. So instead of giving them the pleasure of taking my baby, I gave her up. I was still working for the M family and I was encouraged by a few people. My daughter was removed from my arms by policy of Welfare 5 days after she was born. I never saw my daughter for 20 years, until 2 years ago. He [Carol's employer] more or less encouraged me to put my baby up for adoption. Two months after that, he got me in bed. We had a relationship for so long - 4 or 5 years. And then I had a daughter to him. And this is what my trouble is now. I found my daughter, the one I gave up for adoption; but the last one, Tina, she's about 18 now, Mr M never gave me one cent for my daughter for the last 16 years. About a year ago he started helping me out, but then his wife found out, so now he won't help me. So my daughter now has to live in the same town as Mr M, knowing her father's in the same town, yet we could go without food. I reckon he should recognise her, stand up to his responsibilities.

[Carol has tried to document her stay at Beagle Bay but has been told there is no record she was ever there.] I haven't got anything to say I've been to Beagle Bay. It's only memories and people that I was there with. I don't exist in this world. I haven't got anything, nothing to say who I am.

Confidential evidence 504, Western Australia.