National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2017-2023

All governments are committed to improving social and emotional wellbeing and mental health outcomes for First Australians. We respectfully recognise the diverse cultures and histories of Aboriginal and Torres Strait Islander peoples and we are determined to make a difference by working in partnership to shape approaches that we know will work.

We are therefore pleased to present the renewed National Strategic Framework for Aboriginal and Torres Strait Islander Peoples' Mental Health and Social and Emotional Wellbeing 2017-2023. We would like to thank the members of the Aboriginal and Torres Strait Islander Mental Health and Suicide Prevention Advisory Group for their invaluable leadership and expertise in developing the Framework, along with significant input from Indigenous communities.

This Framework provides a dedicated focus on Aboriginal and Torres Strait Islander social and emotional wellbeing and mental health. It sets out a comprehensive and culturally appropriate stepped care model that is equally applicable to both Indigenous specific and mainstream health services. It will help guide and support Indigenous mental health policy and practice over the next five years and be an important resource for policy makers, advocates, service providers, clients, consumers and researchers.

During this period of rapid reform in Indigenous health, mental health and suicide prevention, this Framework reminds us that culture is central to the health and wellbeing of Aboriginal and Torres Strait Islander peoples. By ensuring cultural considerations are embedded in practice, Aboriginal and Torres Strait Islander peoples will have much better access to culturally safe, responsive, person-centred services provided by a culturally competent and confident workforce.

This Framework has been designed to complement the Fifth National Mental Health and Suicide Prevention Plan and contribute to the vision of the National Aboriginal and Torres Strait Islander Health Plan 2012-2023. It therefore forms an essential component of the national response to Aboriginal and Torres Strait Islander health.

We strongly encourage you to learn from the concepts and strategies provided in this Framework and help us work together to improve the social and emotional wellbeing of Aboriginal and Torres Strait Islander peoples.

Senator the Hon Nigel Scullion
Minister for Indigenous Affairs

The Hon Greg Hunt MP
Minister for Health
Minister for Sport

The Hon Ken Wyatt AM, MP
Minister for Aged Care
Minister for Indigenous Health

Background

The landmark 1995 Ways Forward report was the first national analysis of Aboriginal and Torres Strait Islander mental health and social and emotional wellbeing. The report led to dedicated activities across the areas of suicide, trauma and grief, research and data, and mental health workforce training and development. Importantly, it supported the development of strengths-based, culturally appropriate, community-led primary mental health and social and emotional wellbeing services and programs for Aboriginal and Torres Strait Islander peoples.¹

The National Strategic Framework for Aboriginal and Torres Strait Islander Peoples' Mental Health and Social and Emotional Wellbeing 2004-2009 (2004 Framework) continued efforts to implement the Ways Forward report by providing a dedicated focus on Aboriginal and Torres Strait Islander social and emotional wellbeing and mental health². In that way it complemented the National Mental Health Plan 2003-2008 and the National Strategic Framework for Aboriginal and Torres Strait Islander Health 2003-2013. In November 2011, the Mental Health Standing Committee of the Australian Health Ministers' Advisory Council began the 2004 Framework's renewal on behalf of of the Council of Australian Governments.³

This renewed National Strategic Framework for Aboriginal and Torres Strait Islander Peoples' Mental Health and Social and Emotional Wellbeing 2017-2023 has been developed under the auspice of the Aboriginal and Torres Strait Islander Mental Health and Suicide Prevention Advisory Group, which was appointed to undertake this task.

Purpose

This renewed Framework is intended to guide and inform Aboriginal and Torres Strait Islander mental health and wellbeing reforms.

It aims to respond to the high incidence of social and emotional wellbeing problems and mental ill-health, by providing a Framework for action. Further statistical information about Aboriginal and Torres Strait Islander mental health and related areas and service use is at Appendix 1.

It also aims to contribute to the vision of the National Aboriginal and Torres Strait Islander Health Plan 2012-2023, which includes achieving the Council of Australian Governments' Closing the Gap target for Aboriginal and Torres Strait Islander and non-Indigenous life expectancy equality (as a measure of health equality) by 2031.

Finally, the Australian Government has committed to continue to seek advice from Aboriginal and Torres Strait Islander mental health and related areas leaders and stakeholders to shape reform at the national level⁴. This Framework is also intended to support this ongoing process.

Principles

The nine guiding principles for this Framework are drawn from the Ways Forward report and the 2004 Framework to emphasise the holistic and whole-of-life definition of health held by Aboriginal and Torres Strait Islander peoples.

1. Aboriginal and Torres Strait Islander health is viewed in a holistic context, that encompasses mental health and physical, cultural and spiritual health. Land is central to wellbeing. Crucially, it must be understood that when the harmony of these interrelations is disrupted, Aboriginal and Torres Strait Islander ill health will persist.
2. Self-determination is central to the provision of Aboriginal and Torres Strait Islander health services.
3. Culturally valid understandings must shape the provision of services and must guide assessment, care and management of Aboriginal and Torres Strait Islander people's health problems generally, and mental health problems, in particular.
4. It must be recognised that the experiences of trauma and loss, present since European invasion, are a direct outcome of the disruption to cultural wellbeing. Trauma and loss of this magnitude continues to have inter-generational effects.
5. The human rights of Aboriginal and Torres Strait Islander people must be recognised and respected. Failure to respect these human rights constitutes continuous disruption to mental health. Human rights relevant to mental illness must be specifically addressed.
6. Racism, stigma, environmental adversity and social disadvantage constitute ongoing stressors and have negative impacts on Aboriginal and Torres Strait Islander peoples' mental health and wellbeing.
7. The centrality of Aboriginal and Torres Strait Islander family and kinship must be recognised as well as the broader concepts of family and the bonds of reciprocal affection, responsibility and sharing.
8. There is no single Aboriginal or Torres Strait Islander culture or group, but numerous groupings, languages, kinships, and tribes, as well as ways of living. Furthermore, Aboriginal and Torres Strait Islander people may currently live in urban, rural or remote settings, in traditional or other lifestyles, and frequently move between these ways of living.
9. It must be recognised that Aboriginal and Torres Strait Islander people have great strengths, creativity and endurance and a deep understanding of the relationships between human beings and their environment.

Guide to using this Framework

Mental health and social and emotional wellbeing affects us all. In striving for better mental health and social and emotional wellbeing outcomes for Aboriginal and Torres Strait Islander individuals, families and communities, this document can assist to:

• Understand the mental health reforms which impact most on Aboriginal and Torres Strait Islander mental health and social and emotional wellbeing.
• Understand expected service provision.
• Guide the development and direction of mental health and social and emotional wellbeing programs.
• Guide and support Primary Health Networks and other relevant providers in planning and commissioning culturally and clinically appropriate mental health services for Aboriginal and Torres Strait Islander people.
• Frame integrated Aboriginal and Torres Strait Islander mental health and social and emotional wellbeing activities.
• Inform policy development, research and evaluation.
• Support program implementation.

Aboriginal and Torres Strait Islander peoples share the consequences of colonisation and as a result can face similar challenges today. However, they also have different cultures and histories and in many instances different needs in relation to the challenges they face. The differences must be acknowledged and may need to be addressed by locally developed, specific strategies. 

Audience for this Framework

Government Policy Makers and Advocates

• Health departments at the national, state and territory levels.
• Agencies which cover the following portfolio areas: disability, environment, education, employment, training, justice, family and community services.
• Peak bodies.

State/Territory/Regional Governance Committees

• Aboriginal and Torres Strait Islander organisations.
• State/Territory/Regional-based forums.
• Primary Health Networks.
• Local Hospital Networks.

Workforce

• Professional bodies.
• Psychologists and psychiatrists.
• General practitioners and allied health professionals.
• Social workers, mental health workers, counsellors, Link Up workers, and Aboriginal and Torres Strait Islander Health Workers.
• Administrators.

Services

• Aboriginal Community Controlled Health Services.
• Other Aboriginal and Torres Strait Islander community organisations.
• Mental health services.
• Alcohol and other drug rehabilitation services.
• Child and maternal health services.
• Emergency services.
• Non-government organisations.

Clients

• Individuals, family, friends and carers.

Research/Teaching and Learning

• Educators, evaluators, researchers, and academics.

Policy Context

The National Strategic Framework for Aboriginal and Torres Strait Islander Peoples' Mental Health and Social and Emotional Wellbeing 2017-2023 is a critical part of ongoing reform to the mental health system and interconnected with a number of strategic responses to Aboriginal and Torres Strait Islander health including:

• The National Aboriginal and Torres Strait Islander Health Plan 2013-2023, and its Implementation Plan (2015). These support the national effort led by the Council of Australian Governments to close the health and life expectancy gap between Aboriginal and Torres Strait Islander people and non-Indigenous people by 2031. The Health Plan and its Implementation Plan with their focus on physical health and chronic disease are complemented by the social and emotional wellbeing and mental health focus of this Framework. Not only does a significant gap between Aboriginal and Torres Strait Islander and non-Indigenous mental health outcomes persist, but studies indicate that mental health and related problems make up a significant contribution to the overall health gap.⁵
• The 2013 National Aboriginal and Torres Strait Islander Suicide Prevention Strategy, which requires its implementation to be in alignment with the principles of this Framework.⁶
• The National Aboriginal and Torres Strait Islander Drug Strategy 2014-2019, which addresses the use of alcohol, tobacco and other drugs as part of a comprehensive, holistic approach to health that includes physical, spiritual, cultural, emotional and social wellbeing, community development and capacity building.⁷

Further, this Framework will:

• Complement the overarching, general population Fifth National Mental Health and Suicide Prevention Plan with a dedicated focus on Aboriginal and Torres Strait Islander social and emotional wellbeing and mental health.
• Complement the Primary Health Network's National Service Planning Framework. The Primary Health Networks are required to prepare a mental health service plan that addresses the needs of Aboriginal and Torres Strait Islander people in their region as a part of their overall responsibilities.⁸ This Framework should inform this process as Primary Health Networks work in partnership with Aboriginal and Torres Strait Islander communities, stakeholders and Aboriginal Community Controlled Health Services within their jurisdictions to that end.
• Inform the mental health system as it works in partnership with Aboriginal and Torres Strait Islander people to provide a comprehensive, culturally appropriate stepped care approach incorporating the delivery of both Aboriginal and Torres Strait Islander–specific and mainstream services.⁹

The Australian Government has in place, or is developing, the following important strategies that also relate to this Framework:

• National Framework for Health Services for Aboriginal and Torres Strait Islander Children and Families.
• National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework 2016-2023.
• National Disability Strategy 2010-2020.
• Australian Government Plan to Improve Outcomes for [ATSI] Peoples with a Disability.
• National Disability Insurance Agency Aboriginal and Torres Strait Islander Engagement Plan.
• National Framework for Action on Dementia (2015-2019).

These strategies recognise the importance of mental health and social and emotional wellbeing to achieving their aims for improved Aboriginal and Torres Strait Islander health and wellbeing outcomes.

State and Territory governments also have strategic mental health and suicide prevention policy documents which complement this Framework.

Social and emotional wellbeing

In broad terms, social and emotional wellbeing is the foundation for physical and mental health for Aboriginal and Torres Strait Islander peoples. It is a holistic concept which results from a network of relationships between individuals, family, kin and community. It also recognises the importance of connection to land, culture, spirituality and ancestry, and how these affect the individual.¹⁰

Social and emotional wellbeing may change across the life course: what is important to a child's social and emotional wellbeing may be quite different to what is important to an Elder. However, across the life course a positive sense of social and emotional wellbeing is essential for Aboriginal and Torres Strait Islander people to lead successful and fulfilling lives.¹¹

Aboriginal and Torres Strait Islander people's understanding of social and emotional wellbeing varies between different cultural groups and individuals.¹²

Model of social and emotional wellbeing

In Diagram 1 a model of social and emotional wellbeing with seven overlapping domains is proposed including: body; mind and emotions; family and kin; community; culture; country; and spirituality and ancestors.

With reference to the model, the seven social and emotional wellbeing domains are optimally sources of wellbeing and connection that support a strong and positive Aboriginal and/ or Torres Strait Islander identity grounded within a collectivist perspective.¹³

Culture and cultural identity is critical to social and emotional wellbeing. Practising culture can involve a living relationship with ancestors, the spiritual dimension of existence, and connection to country and language.¹⁴ Individual and community control over their physical environment, dignity and self-esteem, respect for Aboriginal and Torres Strait Islander peoples' rights and a perception of just and fair treatment is also important to social and emotional wellbeing.¹⁵

Diagram 1: A Model of Social and Emotional Wellbeing¹⁶

Culture is therefore critically important in the delivery of health services. As noted in the National Aboriginal and Torres Strait Islander Health Plan 2013-2023:

Culture can influence Aboriginal and Torres Strait Islander people's decisions about when and why they should seek health services, their acceptance of treatment, the likelihood of adherence to treatment and follow up, and the likely success of prevention and health promotion strategies...¹⁷

Social and emotional wellbeing is affected by the social determinants of health including education and unemployment and a broader range of problems resulting from colonisation and its intergenerational legacies: grief and loss, trauma and abuse, violence, removal from family and cultural dislocation, substance abuse, racism and discrimination and social disadvantage.¹⁸

Stressful life events and psychological distress are linked. Aboriginal and Torres Strait Islander people are exposed to stressful life events at higher rates than their non-Indigenous peers. In the 2012-13 Australian Bureau of Statistics Australian Aboriginal and Torres Strait Islander Health Survey, 73 per cent of respondents aged 15 years and over reported that they, their family or friends had experienced one or more stressful life events in the previous year. Exposure to such was reported at 1.4 times the rate of non-Indigenous people.¹⁹

Many life stressors stem from the contemporary experience of inequalities across key social determinants - including deep and entrenched disadvantage and social exclusion. For some individuals, families and communities, entrenched disadvantage is intergenerational and linked to the dispossession of land, policies of discrimination and child removals associated with colonisation.²⁰

For Aboriginal and Torres Strait Islander people with weakened social and emotional wellbeing, care is effective when multi- dimensional solutions are provided, which build on existing community, family and individual strengths and capacity and may include counselling and social support, culturally informed practice and, where necessary, support during family reunification.²¹

Cultural healers play an important role in maintaining and healing social and emotional wellbeing. Today, health services will optimally combine traditional healing and treatments informed by culture with western, clinical approaches for the wellbeing of the whole Aboriginal and Torres Strait Islander person.²² In particular, the important role of cultural healers (like the Ngangkari - traditional healers of the Ngaanyatjarra Pitjantjatjara Yankunytjatjara Lands), Elders, and others can play working with spiritual wellbeing in the health and correctional centres space is acknowledged.

Social and emotional wellbeing provides a foundation for effective physical and mental health promotion strategies.²³ Promoting social and emotional wellbeing is about maximising the benefits of the protective factors that connect and support wellbeing, while minimising exposure to risk factors and particularly those that are also risk factors for mental health conditions.²⁴

The risk and protective factors to mental health occur in everyday life. Protective factors are seen to strengthen positive mental health and social and emotional wellbeing and help people to be resilient in times of adversity.

Protective and risk factors are outlined further in Table 1 on the following page.

Table 1: The Domains of Social and Emotional Wellbeing with Risk and Protective Factors

Useful mental health and related concepts

Social and emotional wellbeing problems are distinct from mental health problems and mental illness, although they can interact with and influence each other. Even with good social and emotional wellbeing, people can still experience mental illness. Further, people with a mental health problems or mental illness can live and function at a high level with adequate support and they continue to have social and emotional wellbeing needs.

Cognitive Impairment or Disability

A person living with a cognitive impairment or disability does not have a mental illness but may have lower capacity for emotional control and poorer intellectual and language development. People with a cognitive impairment or disability are at greater risk of mental health and behavioural problems, substance abuse disorders and coming into contact with the criminal justice system.²⁵

Cultural Determinants

Cultural determinants can inform a strengths based approach to Aboriginal and Torres Strait Islander mental health. They acknowledge that stronger connections to culture and country build stronger individual and collective identities, a sense of self-esteem, resilience, and improved outcomes across the other determinants of health including education, economic stability and community safety.²⁶

Mental Health

Mental health is a positive state of wellbeing in which the individual can manage their thoughts and feelings. In this way a person can cope with the normal stress of life and reach his or her potential in work and community life in the context of family, community, culture and broader society.²⁷

Mental Health Problems and Psychological Distress

Mental health problems are ‘diminished cognitive, emotional or social abilities but not to the extent that the criteria for a mental illness are met.'²⁸ An example is generalised psychological distress. This can be a mixture of emotional distress and anxiety, and depression-related symptoms such as worry, and disturbed sleep. Serious psychological distress can be seen as a warning sign that someone is not coping, that mental health is at risk, and that a person is at an increased risk of substance abuse disorders and suicide. It can also cause mental illness to recur and worsen existing conditions.²⁹

Mental Illnesses

Mental Illnesses are diagnosed according to certain criteria.³⁰ They range from high prevalence disorders such as anxiety and depression through to low prevalence disorders such as psychosis, schizophrenia, and bi-polar disorder. Further, mental illnesses range from mild to moderate, single episodes with or without full recovery to severe and ongoing mental illnesses. Many people may experience an episode of mental illness and make a full recovery, but nonetheless remain vulnerable to stressful life events and psychological distress and need social and emotional wellbeing support.

Person- Centred Care

Person-centred care is a way of thinking and doing things that sees the people using health and social services as equal partners in planning, developing and monitoring care to make sure it suits their needs. This means putting people and their families at the centre of decision-making around their treatment and care and seeing them as experts in these areas, working alongside professionals to get the best outcome.³¹

Psychosocial Disability

Psychosocial disability as a concept has become important as an eligibility requirement for people living with mental illness seeking support under the National Disability Insurance Scheme. Psychosocial disability describes the experience of people with impairments and participation restrictions related to mental health conditions. These impairments can include a loss of ability to function, think clearly, experience full physical health, and manage the social and emotional aspects of their lives.³² Not everyone with a mental illness will have a level of impairment that will result in a psychosocial disability.

Recovery

Recovery is an important concept for people living with mental illness. For the purposes of the National Framework for Recovery-Oriented Mental Health Services, it is defined as ‘being able to create and live a meaningful and contributing life in a community of choice with or without the presence of mental health issues'. Recovery-oriented practice supports the possibilities for recovery and wellbeing despite the experience of mental health problems or illness.³³

Resilience

Resilience consists of various processes, ways of thinking and acting through which individuals adapt and cope well with adversity, without suffering from long term harmful consequences due to stress.³⁴ Resilience can mean different things in different contexts and is a dynamic process rather than a fixed state.

Social Determinants

Social determinants are the conditions in which people are born, grow, live, work and age. A social determinants of health approach considers the broad social, political, economic, cultural and environmental context in which people live and the impact these have on health and wellbeing. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.³⁵

Strengths Based Approach

A strengths based approach recognises the resilience of individuals and communities. It focuses on abilities, knowledge and capacities rather than a deficits based approach which focuses on what people do not know, or cannot do, problematising the issue or victimising people. It recognises that the community is a rich source of resources; assumes that people are able to learn, grow and change; encourages positive expectations of children as learners and is characterised by collaborative relationships. It focuses on those attributes and resources that may enable adaptive functioning and positive outcomes.³⁶

Substance Abuse Disorders

Substance abuse disorders including addictions involving substances (including alcohol, cannabis, inhalants, and stimulants such as amphetamines) are classified as mental health disorders on a continuum ranging from mild to severe. Substance abuse disorders can be considered as mental health problems because they are associated with damage to mental health, for example, depressive and psychotic disorders.³⁷

Trauma

Trauma is not mental illness but refers to experiences and symptoms associated with particularly intense stressful life events that overwhelm a person's ability to cope. For children and adults, these can include physical, emotional or sexual abuse. Responses in adults can include a range of symptoms including, but not limited to, psychotic breakdown and post-traumatic stress. For Aboriginal and Torres Strait Islander people, intergenerational, and trans-generational trauma are also relevant.³⁸ The limited data available suggests relatively high levels of trauma in the Aboriginal and Torres Strait Islander population.³⁹ Frontline and health services should be culturally informed and trauma informed to work effectively with Aboriginal and Torres Strait Islander people, and particularly children, living with trauma.

The stepped care model for primary mental health care service delivery

The Australian Government has moved to a stepped care model for primary mental health care service delivery and this has formed the basis of the Action Areas outlined in this Framework. Stepped Care is a system of delivering and monitoring treatments so that the most effective yet least resource intensive treatment is delivered to clients first; only ‘stepping up' to intensive/specialist services as clinically required. Stepped care is seen as essential to improving service integration and navigation through the system and to optimising the use of available resources.

This means that a broader range of services should be available which are better targeted to individual needs, and that individuals and families are assisted to access the most suitable service. Primary Health Networks will have a key role in commissioning appropriate services and facilitating integration with other relevant supports at the regional level. This will include facilitating linkages between clinical and non-clinical supports, particularly for people with severe and complex mental illness. The approach to strengthening primary care through a stepped care model is summarised in Diagram 2.

Diagram 2: System changes to strengthen the stepped care model in primary mental health care service delivery

Source: The Australian Government Response to Contributing Lives, Thriving Communities – Review of Mental Health Programmes and Services (2015)

This Framework aims to fundamentally shift the way mental health programs and services are delivered for Aboriginal and Torres Strait Islander peoples. To that end, it has been informed by the 2015 Australian Government response to the National Review of Mental Health Programmes and Services, and the National Aboriginal and Torres Strait Islander Health Plan 2013-2023 and its 2015 Implementation Plan.

Aboriginal and Torres Strait Islander leadership and partnership

Aboriginal and Torres Strait Islander leadership, engagement and partnership in the planning, delivery, evaluation, and measurement of services and programs is critical in fostering greater trust, connectivity, culturally appropriate care and effective outcomes.

• At the national level, Australian Government partnerships with recognised Aboriginal and Torres Strait Islander health and mental health leadership and advisory groups are important.
• At the state and territory level, Aboriginal and Torres Strait Islander health planning fora provide the vehicle for sharing information on health needs and undertaking joint planning to inform resource allocation.
• At the regional level, effective partnerships and synergies between Aboriginal Community Controlled Health Services and other Aboriginal and Torres Strait Islander health and related services, communities, Primary Health Networks, Local Hospital Networks, general practitioners and other mainstream stakeholders are critical to improving mental health outcomes in communities.

Social determinants of mental health

Social determinants contribute to the high number of adverse childhood experiences and stressful life events experienced by Aboriginal and Torres Strait Islander people when compared to non-Indigenous people.

The causal pathways between social determinants and health are complex and multi-directional. Addressing social determinants requires a collaborative approach that includes services outside the health sector including housing, education, employment, recreation, family services, crime prevention and justice.⁴⁰

Effective approaches are characteried by:⁴¹

• Holistic approaches.
• Cross sectoral and inter-governmental action.
• Valuing Aboriginal and Torres Strait Islander knowledges, cultural beliefs and practices.
• Collaborative working relationships.
• Supported active involvement of Aboriginal and Torres Strait Islander communities at every stage of program development and delivery.
• Clear Aboriginal and Torres Strait Islander leadership and governance for programs.
• Aboriginal and Torres Strait Islander staff employed at all levels.
• Cultural safety policies and procedures.
• Developing and retaining skilled and committed staff.
• Sustainable resources.
• Being strengths based.
• Research and evaluation.

Addressing racism

The National Aboriginal and Torres Strait Islander Health Plan's vision includes that ‘the Australian health system is free of racism and inequality for all Aboriginal and Torres Strait Islander people.'⁴²

At every point with the health system, the opportunity exists to provide care that is culturally safe, high quality, responsive and accessible for all Aboriginal and Torres Strait Islander people.

Racism has a negative effect on the social and emotional wellbeing of Aboriginal and Torres Strait Islander peoples. Racism is experienced by a significant proportion of Aboriginal and Torres Strait Islander people in daily life.⁴³

Emerging evidence suggests that well designed universal and targeted interventions across different settings, organisational development, communications, social marketing and direct participation programs might be required to address racism. Some ways include:

• Disseminating information on the effects of racism on Aboriginal and/or Torres Strait Islander people.
• Challenging false beliefs and stereotypes and providing accurate information about Aboriginal and Torres Strait Islander peoples and cultures.
• Aboriginal and Torres Strait Islander people leading in program design and development.⁴⁴

For further information see the 2012 National Anti-Racism Strategy.⁴⁵

Ensuring services are culturally respectful is a primary way to ensure services for Aboriginal and Torres Strait Islander people are person-centred. The National Cultural Respect Framework for Aboriginal and Torres Strait Islander Health 2016-2026 defines cultural respect as:

Recognition, protection and continued advancement of the inherent rights, cultures and traditions of Aboriginal and Torres Strait Islander people.⁴⁶

The vision of the Cultural Respect Framework is that the Australian health system is accessible, responsive and safe for Aboriginal and Torres Strait Islander peoples, and where cultural values, strengths and differences are recognised and incorporated into the governance, management and delivery of health services. The Cultural Respect Framework commits Australian governments to embedding cultural respect principles into their health systems. It is intended to guide and underpin the delivery of quality, culturally safe, responsive health care to Aboriginal and Torres Strait Islander peoples.⁴⁷

Person-centred care

A renewed focus on the person/client at the centre of care is a foundation approach to mental health reform. That is, a focus on what the client needs from, and their access to, health, mental health and broader services, and meeting their wider social needs in a connected and coordinated way. This person-centred approach to care is intended to be underpinned by person-centred funding arrangements and better targeted referrals by general practitioners.⁴⁸

Building effective services, programs and integrated pathways around the individual needs of Aboriginal and Torres Strait Islander people requires services to:

• Be clinically appropriate.
• Be trauma-informed.
• Be culturally respectful.
• Develop culturally safe protocols.
• Employ workers, paraprofessionals and professionals who are culturally competent.
• Involve Aboriginal and Torres Strait Islander peoples in the design and assessment of mental health and related areas programs and services.
• Recognise carers as key partners in achieving better outcomes for people living with mental illness.⁴⁹

Focusing on the specific needs of the person living with mental illness is also an essential part of a recovery-oriented mental health system.

Person-centred care is also important for those Aboriginal and Torres Strait Islander people living with psychosocial disability including those eligible for support through the National Disability Insurance Scheme. Choice and control is a key concept for the National Disability Insurance Scheme.

Focus on children and young people

There is clear evidence that preventative action and appropriate early childhood interventions can be a key to better mental health and other benefits across the lifecourse. Focusing on mental health problems early in life is an important preventative population health measure. Developing resilience early in life is linked to long term occupational and life success and the prevention of substance abuse, violence and suicide. It can be expected to have benefits across the life course: supporting educational attainment, employment opportunities and physical health. And further, support those people to better parent the generation that follow.⁵⁰

Aboriginal and Torres Strait Islander families and children have a much higher recorded prevalence of exposure to stressful life events than non-Indigenous families and children.⁵¹ In particular, in 2015-16, Aboriginal and Torres Strait Islander children were seven times as likely as non-Indigenous children to be receiving child protection services.⁵² The most common types of substantiated abuse for Aboriginal and Torres Strait Islander children were emotional abuse, which represented 39 per cent of substantiations; neglect, (36 per cent). Sexual abuse was the least common type of substantiation (9 per cent).⁵³

Emotional and behavioural difficulties which can result from exposure to adverse childhood experiences or stressful life events may include a diverse patterns of symptoms including anxiety, depressive disorders, drug and alcohol use, psychosis and suicidal behaviour.⁵⁴

Effective approaches are characterised by, but not exclusively:

• Good parenting which is critical to a child's adult mental health and wellbeing.⁵⁵
• Integrated services which connect providers, families and schools to information and supports which are needed to get the best services and outcomes for children.⁵⁶

Integrated approaches

As social and emotional wellbeing problems, mental health problems, substance abuse disorders, suicide and the impacts of suicide in families and communities interact and influence each other, the greater integration of services for these areas is a reform goal of the Australian Government, and is a critical part of this Framework.

Regardless of the treatment setting, most people living with mental illnesses and substance abuse disorders need to be able to access three streams of integrated care:

• General practitioner provided medical care including pharmacotherapies of all types and mental health care plans to access psychological care, as well as supporting continuity of care across the mental health system.
• Psychological care by a range of mental health professionals, paraprofessionals and workers providing structured therapies including cognitive behavioural therapy, dialectical behavioral therapy, mindfulness, and other evidence based therapeutic approaches as appropriate.
• Social and cultural support, including case management when needed. This is the key to long term rehabilitation including vocational rehabilitation.

Better supporting substance abuse services to identify and treat coinciding mental illness and substance abuse disorders (including those involving methamphetamine or 'ice') by greater service integration is a critical element of this Framework. The three streams of integrated care also need to be available to these services.

Suicide is a behaviour rather than a mental illness, and what contributes to each suicide will be different. However, there are associations between suicide, substance abuse disorders and mental illness. In particular, severe depression is associated with suicide.⁵⁷ As such, mental health services and substance abuse services should be able to respond to a person presenting at risk of suicide as a part of their service capabilities.

Importantly, intensive case management may be necessary for some clients to ensure continuity of social and emotional wellbeing support and advocacy is provided to them. Logically, such an integrated approach will be delivered by one provider and Aboriginal Community Controlled Health Services are well placed to do so in the communities they serve. It may otherwise require collaboration, partnerships, consultation and liaison, or joint case management across services, including specialist mental health, primary health care, Aboriginal Community Controlled Health Services and other support agencies, as necessary, to ensure holistic, person-centred case management and follow up of co-morbidities.

Regional service integration is the responsibility of Primary Health Networks and Local Hospital Networks. The Primary Health Networks' integration activities will be guided by a National Service Planning Framework (see also Appendices 2 and 3 for illustrative case studies and further information about integrated service delivery).

Trauma-informed care

Trauma informed care is grounded in an understanding of and responsiveness to the impact of trauma on wellbeing. The Closing the Gap Clearinghouse paper: Trauma-Informed Services and Trauma-Specific Care for Indigenous Australian Children, states that services that are trauma informed:

• Understand trauma and its impact on individuals (such as children), families and communal groups.
• Create environments in which children feel physically and emotionally safe.
• Employ culturally competent staff and adopt practices that acknowledge and demonstrate respect for specific cultural backgrounds.
• Support victims/survivors of trauma to regain a sense of control over their daily lives and actively involve them in the healing journey.
• Share power and governance, including involving community members in the design and evaluation of programs.
• Integrate and coordinate care to meet children's needs holistically.
• Support safe relationship building as a means of promoting healing and recovery.⁵⁸

Culturally appropriate, affordable care

For Aboriginal and Torres Strait Islander people, services must be culturally appropriate if they are to meet the above requirements and be person-centred. In this Framework, ‘culturally appropriate' services refer to those that are culturally competent and culturally safe.

Cultural competencies are a skill set that can be gained by experience working with Aboriginal and Torres Strait Islander people and by training modules. It includes:

• Cultural Awareness: Understanding the role of cultural difference and diversity. For non-Indigenous staff this means the capacity for self-reflection as to how the Western dominant culture impacts on both themselves and on Aboriginal and Torres Strait Islander people, and can impact the service setting they operate in.
• Cultural Respect: Valuing Aboriginal and Torres Strait Islander people and cultures. This includes a commitment to self-determination and building respectful partnerships.
• Cultural Responsiveness: Having the ability and skills to assist people of a different culture other than your own.⁵⁹

Aboriginal Community Controlled Health Services range from large services with several medical practitioners, visiting specialists, and social health teams who provide counselling and other supports, to small services that rely on nurses and/or Aboriginal and Torres Strait Islander Health Workers to provide most services. They are well placed to provide accessible, culturally appropriate care to the communities they serve because they:

• Are operated by and situated in local Aboriginal and Torres Strait Islander communities.
• Deliver comprehensive, holistic and culturally safe and competent health care to their communities.
• Are controlled through a locally elected board of management.
• Are affordable to community members as bulk billing is available.⁶⁰

Services, inclusive of mental health services, who do not, or are yet to develop cultural safety practices, are at risk of indirectly discriminating against Aboriginal and Torres Strait Islander people by placing cultural barriers in the way of accessing the same services as other Australians.

Culturally safe service environments are welcoming for Aboriginal and Torres Strait Islander people. The visible presence of Aboriginal and Torres Strait Islander staff has been demonstrated to increase the accessibility of services by contributing to a sense of cultural safety, and otherwise by helping 'acculturate' the service.⁶¹

Cultural safety involves an understanding that there are power relations in and between all cultural groups and at all levels. From this basis, services are able to work on addressing cultural inequities in health in safe ways.

Cultural safety is a model of practice which respects everyone's identity and human right to responsive, respectful, timely and accessible high quality health care.

Cultural safety is also about the right of Aboriginal and Torres Strait Islander people to work free from discrimination, where cultural heritage and ways of working are valued as core strengths, and that at an individual level everyone feels culturally secure, safe and respected.

Cultural safety builds on knowledges, tools and resources reflective of Aboriginal and Torres Strait Islander principles and ways of working. It includes cultural awareness, cultural sensitivity, cultural knowledge, cultural respect and builds the cultural capabilities of the health workforce.

Clinically appropriate care

Treatment for mental health and related problems can occur in primary health care or specialist mental health settings. It can include early intervention, treatment and monitoring, relapse prevention and access to specialist services, rehabilitation and long term support. Services must be clinically and culturally appropriate and safe, and provide continuity of care across the life course.

With reference to the National Mental Health Performance Framework, Tier III System Performance Indicators,⁶² this must encompass the following clinical quality indicators, referred to as ‘clinically appropriate' in this Framework:

• Accessibility: The ability of people to obtain health care at the right place and time irrespective of income, geography and cultural background.
• Appropriateness: The care, intervention or action provided is relevant to the client's and/or carer's needs and based on established standards.
• Capability: An individual or service's capacity to provide a health service based on skills and knowledge.
• Continuity of care: Ability to provide uninterrupted, coordinated care or service across programs, practitioners, organisations and levels over time.
• Effectiveness: Care, intervention or action achieves desired outcome.
• Efficiency: Achieving desired results with most cost effective use of resources.

Vision

For Aboriginal and Torres Strait Islander people, families and communities to achieve and sustain the highest attainable standard of social and emotional wellbeing and mental health supported by mental health and related services that are effective, high quality, clinically and culturally appropriate, and affordable.

Actions Area and Outcomes

These Action Areas and Outcomes are based on a stepped care model of primary mental health care service delivery.

Outcome 1.1: An effective and empowered mental health and social and emotional wellbeing workforce

Rationale: A highly skilled and supported workforce, operating in a clinically and culturally competent way, is required to meet the mental health needs of Aboriginal and Torres Strait Islander people.

Key strategies

1. Incorporate specific Aboriginal and Torres Strait Islander leadership in workforce program development.
2. Increase Aboriginal and Torres Strait Islander employment across the entire mental health and social and emotional wellbeing workforce, including psychologists and psychiatrists, speech pathologists, mental health workers and other professionals and workers (see Appendix 2 for further information).
3. Give priority support to the further development of social and emotional wellbeing teams within Aboriginal Community Controlled Health Services (see Appendix 3 for further information).
4. Create career pathways by reducing barriers and pathways to education and training including training for emerging professional workforces accredited workers, paraprofessionals and established professionals and professions.
5. Improve the status of all Aboriginal and Torres Strait Islander mental health and social and emotional wellbeing workers, paraprofessionals and professionals and over time, require workers to have qualifications that ensure professional equity.
6. Continue to develop accreditation standards that are systematically measurable; and develop and support pathways to training in existing work environments to increase worker and professional capacities.
7. Progress initiatives that support quality service delivery, quality improvement processes and workforce-wide up-skilling, including appropriate clinical supervision of mental health and social and emotional wellbeing workers, paraprofessionals and professionals.
8. Ensure that workers, emerging workforces and professional services qualify for Medicare Benefits Schedule subsidies.
9. Recognise traditional healers, Elders and other cultural healers as an essential part of the overall social and emotional wellbeing and mental health areas workforce.
10. Require cultural competence of general practitioners and other medical practitioners in order to work effectively with Aboriginal and Torres Strait Islander people with mental health problems and mental illness.
11. Ensure alignment of measurable professional training and education standards and service accreditation standards to ensure a system wide approach to improving reportable capabilities for working effectively with Aboriginal and Torres Strait Islander people.
12. Improve national access to vocational training in key evidence based therapies (for example, cognitive behavioural therapy, dialectical behavioural therapy and mindfulness therapies).
13. Increase Aboriginal and Torres Strait Islander participation rates in tertiary courses.
14. Encourage the development of specialist Aboriginal and Torres Strait Islander mental health courses.

Example actions

• Develop and increase knowledge of social and emotional wellbeing concepts and improve the cultural competence and capability of mainstream providers.
• Recognise the importance of Aboriginal and Torres Strait Islander leadership and support implementation of the Gayaa Dhuwi (Proud Spirit) Declaration and reflect its intent in practice (see: http://natsilmh.org.au/sites/default/files/gayaa_dhuwi_declaration_A4.pdf).
• Train all staff delivering mental health services to Aboriginal and Torres Strait Islander people, particularly those in forensic settings, in trauma informed care.
• Primary Health Networks collaborate with Aboriginal Community Controlled Health Services to identify current capacity and future workforce needs.
• Establish/strengthen and support Aboriginal and Torres Strait Islander mental health and social and emotional wellbeing teams.
• Workforce Support Units develop a national Scope of Practice for the SEWB workforce.
• Workforce Support Units work with the vocational sector on relevant vocational competency standards to ensure they are in line with current trends, for example the Australian Government’s Indigenous Health Curriculum Framework.
• Provide access to treatment and care that is appropriate to, and consistent with, Aboriginal and Torres Strait Islander cultural and spiritual beliefs and practices, inclusive of traditional healers, Elders and other cultural healers.
• Development of quality and professional standards with organisations such as the Royal Australian College of General Practitioners, the Australian College of Rural and Remote Medicine, the Royal Australian and New Zealand College of Psychiatrists, Australian Psychological Society and Nursing Associations, the Australian Indigenous Doctors’ Association, and the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives.
• Improve curriculum standards for the education and training of all future accredited professionals and emerging workforces working with Aboriginal and Torres Strait Islander people, for example the Medical Deans of Australia and New Zealand Indigenous Health Curriculum Framework.
• Support Aboriginal and Torres Strait Islander organisations to provide local cultural competence training.

Outcome 1.2: A strong evidence base, including a social and emotional wellbeing and mental health research agenda, under Aboriginal and Torres Strait Islander leadership

Rationale: There is a need to build the evidence base and progress a dedicated Aboriginal and Torres Strait Islander mental health and social and emotional wellbeing research agenda.

Key strategies

1. Strengthen the evidence base needed to inform the development of improved mental health services and outcomes for Aboriginal and Torres Strait Islander people.
2. Ensure future investments in new or expanded services are properly evaluated.
3. Develop culturally appropriate mental health and social and emotional wellbeing assessment tools and clinical pathways, particularly for children and young people.
4. Develop culturally appropriate indicators to measure social and emotional wellbeing.
5. Support practical applied research to progressively enhance service delivery.
6. Promote participatory action research to progressively empower communities and restore and promote social and emotional wellbeing.
7. Embed the principle of Aboriginal and Torres Strait Islander community leadership and control of research in guidelines for the ethical conduct of research with Aboriginal and Torres Strait Islander people.

Example actions

• Establish a clearinghouse of resources, tools and program evaluations to facilitate the development and implementation of culturally safe models of service delivery, including the use of cultural healing and trauma informed care.
• Review population health surveys to explore opportunities for improved data collection on the mental health and wellbeing and the prevalence of mental illness in Aboriginal and Torres Strait Islander people.
• Better harness available health services data and enhance those collections to strengthen the focus on services delivered to Aboriginal and Torres Strait Islander people.

Outcome 1.3: Effective partnerships between Primary Health Networks and Aboriginal Community Controlled Health Services

Rationale: Mental health is one of six Primary Health Network priority areas and strong effective partnerships between Primary Health Networks and Aboriginal Community Controlled Health Services are important, particularly in relation to service mapping designed to identify gaps and the commissioning of services.

Key strategies

1. Formalise effective partnerships to achieve the best possible social and emotional wellbeing, mental health and related outcomes for Aboriginal and Torres Strait Islander people in all regions, including by implementing integrated planning and service delivery for Aboriginal and Torres Strait Islander people at the regional level.
2. Improve service equity for rural and remote communities and for under-serviced populations, including through place-based models of care.
3. Join up assessment processes and referral pathways to better support:
4. People with severe mental illness, including by the National Disability Insurance Scheme.
5. Children and young people with or at risk of mental illness.
6. Facilitate a regional approach to suicide prevention, including seamless post discharge care.
7. Give preference to funding Aboriginal Community Controlled Health Services to deliver mental health, suicide prevention and other primary health programs and services where feasible.
8. Ensure planning strategies incorporate the joint planning processes of the state and territory-level Aboriginal and Torres Strait Islander health planning fora.
9. Facilitate continuity of care and information sharing between services through the use of the My Health Record.

Example actions

• Primary Health Networks, in collaboration with Local Hospital Networks and Aboriginal Community Controlled Health Services and other health services, develop regional mental health plans based on needs assessment, service mapping, identifying gaps; identifying opportunities for better use of services to reduce duplication and remove inefficiencies; and commissioning services when appropriate.
• Primary Health Networks work with Aboriginal Community Controlled Health Services in building their capacity to provide mental health and social and emotional wellbeing services as part of an integrated primary health care model.
• Engage Aboriginal and Torres Strait Islander communities in the co-design of all aspects of regional planning and service delivery.
• Use the National Mental Health Service Planning Framework to better meet the needs of Aboriginal and Torres Strait Islander populations and incorporate Aboriginal Community Controlled Health Services in care packages.
• Collaborate with service providers regionally to improve referral pathways between general practitioners, Aboriginal Community Controlled Health Services, social and emotional wellbeing, disability, alcohol and other drug and mental health services, including improving opportunities for screening of mental and physical wellbeing at all points.
• Primary Health Networks report at the regional and national levels with as much data as possible disaggregated for Aboriginal and Torres Strait Islander peoples.

Outcome 2.1: Aboriginal and Torres Strait Islander communities and cultures are strong and support social and emotional wellbeing and mental health

Rationale: Communities can be sources of support and resilience that promote social and emotional wellbeing when community organisation and functioning is culturally-informed and provides for cultural practice and transmission. For optimal social and emotional wellbeing in individuals and families, empowering communities to heal and to revitalise culture and cultural practices may be required.

Key strategies

1. Support community governance through community controlled services to deliver health programs and services.
2. Empower communities to identify and address challenges.
3. Strengthen community cohesion, and restore and heal connections to culture and country including through reclamation and revitalisation.
4. Engage Elders and senior community members in leadership roles in a culturally-informed way and support communities to support Elder wellbeing.
5. Support men’s and women’s groups and gender-specific promotion of leadership, social and emotional wellbeing and healing.
6. Support communities that wish to restrict alcohol supply and use among their members.
7. Encourage practical outcomes, such as employment of community members, school attendance and educational attainment.
8. Encourage alcohol reduction strategies, including mainstream policy analysis of potential pricing levers and taxation options.

Example actions

• Aboriginal Community Controlled Health Services deliver health programs and services where feasible.
• Support Elders as role models to champion culturally- informed choices and approaches to health and wellbeing.
• Support Elders groups.
• Deliver mental health and related services and programs to men and women through men’s and women’s groups and activities.
• Provide communities with flexible, tailored funding and service arrangements.
• Continue support for the National Aboriginal and Torres Strait Islander Healing Foundation.
• Community empowerment models that respond to local or regional need.

Outcome 2.2: Aboriginal and Torres Strait Islander families are strong and supported

Rationale: Families are pivotal to the wellbeing of individuals and communities, including through the transmission of culture. The way in which families operate can also help family members cope with disadvantage and stressful life experiences. Aboriginal and Torres Strait Islander people can view family structures and relationships differently and child rearing can be practiced more collectively.

Key strategies

1. Increase family-centric and culturally-safe services for families and communities.
2. Support families by providing access to parenting programs and services in relation to early childhood development, family support, health and wellbeing, alcohol and other drugs.
3. Support the role of men and Elders in family life and the raising of children in a culturally-informed way.
4. Support single parent families and extended family and kin support networks.
5. Support family re-unification for members of the Stolen Generations, prisoners, children removed from their families into out-of-home care, and young people in juvenile detention.

Example actions

• Promote the role of Aboriginal Community Controlled Health Services in delivering family social and emotional wellbeing support programs and services and provide relationships counselling and parenting programs.
• Support community-led anti-family violence and child abuse campaigns.
• Non-working families have free access to support programs and early childhood learning centres.

Outcome 2.3: Infants get the best possible developmental start to life and mental health

Rationale: Supporting infants to get the best possible developmental start to life is fundamental to their mental health as young people and adults. Programs to detect and reduce alcohol and substance use among pregnant women are an important part of this outcome because treatment at early stages of pregnancy can help reduce the incidence of cognitive and developmental impairments.

Key strategies

1. Continue implementing the National Early Childhood Development Strategy, including the strengthening of universal maternal and child health services.
2. Support pregnant women, particularly those with substance abuse disorders, to help stop smoking and alcohol consumption to prevent Fetal Alcohol Spectrum Disorders and increase the birth weight of infants.
3. Broaden antenatal care to include support for perinatal depression screening and intervention strategies to reduce maternal stress.
4. Facilitate attachment and security in childhood by increasing access to appropriate parenting programs.
5. Facilitate the measurement of developmental milestones of infants.
6. Facilitate health checks through infancy and childhood, particularly for conditions associated with emotional and behavioural problems such as hearing loss resulting from chronic otitis media.
7. Support the mental health and social and emotional wellbeing of children with cognitive and developmental impairments and disabilities.

Example actions

• Extend the reach of targeted programs into communities including those that support infants, new mothers, and parents/families.
• Detect and support cognitive and developmental impairments and disabilities at an early age and work with children with them to achieve their full potential.
• Provide access to educational day care to provide additional care and stimulation to disadvantaged children from 6 months to age 3 years of age (followed by 2 years of pre-school).

Outcome 2.4: Aboriginal and Torres Strait Islander children and young people get the services and support they need to thrive and grow into mentally healthy adults

Rationale: During early childhood children develop a range of essential capabilities including social, emotional, language, cognitive and communication skills that provide the foundations for formal learning and relationships in later life. In middle childhood physical and mental development occurs and learning and social behaviours are established. During adolescence there is great personal change including physical development, the establishment of a sense of identity and values, and emotional development that can impact relationships and aspirations for the future.

Key strategies

1. Ensure access to culturally appropriate quality pre-school care and education for children aged 3 and 4 and promote school attendance.
2. Adapt end-to-end school based social and emotional wellbeing and mental health programs for Aboriginal and Torres Strait Islander children that include a focus on:
3. Culturally and age appropriate alcohol and drug use prevention and/or reduction.
4. Culturally and age appropriate suicide prevention.
5. Help seeking behaviour and de-stigmatisation of mental health problems.
6. Strengthening pride in identity and culture.
7. Reducing bullying and its mental health impacts.
8. Reducing young people’s contact with the criminal justice system.
9. Addressing the impact of racism and building resilience to racism.
10. Support children and young people’s strong connection to culture and sense of belonging in communities, families and friendship networks as a way to support their resilience and to help protect against suicide.
11. Develop strategic responses to support the social and emotional wellbeing of children in out-of-home care and establish appropriate connections between child protection services and a range of family and child-support services.
12. Support the social and emotional wellbeing and mental health of vulnerable children including those with disabilities and those in carer roles.
13. Require evidence based approaches on mental health and wellbeing be adopted in early childhood worker and teacher training and continuing professional development.

Example actions

• Promote culturally and age appropriate mental health literacy in schools, including through prioritising the development of age and Aboriginal and Torres Strait Islander-specific pathways in the digital mental health gateway.
• Promote age appropriate protective behaviours against sexual abuse in young children and reinforce it over time. In particular, boys are reluctant to report sexual abuse and should be supported to do so.
• Promote the role of Elders in the lives of children and young people to help strengthen culture and community belonging and to enhance support networks.
• Promote whole-of-community vigilance for child safety, and appropriate responses to child abuse and neglect.
• Integrate and coordinate existing programs with school communities to better target school aged children and families on a regional basis, and to get better outcomes from existing program investments (such as KidsMatter and MindMatters).
• Aboriginal Community Controlled Health Services provide a specific service for people between the ages of 12 and 25. Where possible this could be done in partnership with organisations such as headspace.
• Education activities on the mental health and wellbeing benefits of good nutrition.

Outcome 3.1: Access to traditional and contemporary healing practices

Rationale: Healing can happen in many different ways for individuals and communities. Spirituality and specific Aboriginal and Torres Strait Islander healing approaches can play an important role in this regard. Many healing practices and programs occur outside of the responsibility of the health sector. Developing and promoting pathways for healing is an important component of person-centred and holistic care.

Key strategies

1. Develop culturally appropriate treatment pathways within a social and emotional wellbeing framework.
2. Support access to traditional and contemporary healing practices and healers.
3. Support traditional and contemporary healing practices like that of the Ngangkari, cultural healers and Elders alongside other mental health and related services.
4. Support programs for members of the Stolen Generations and their families.

Example actions

• Continued support for the National Aboriginal and Torres Strait Islander Healing Foundation.
• Continued support for family tracing and reunions for members of the Stolen Generations through Link-Up Services.
• Provide access to treatment and care that is appropriate to, and consistent with Aboriginal and Torres Strait Islander cultural and spiritual beliefs and practices, inclusive of traditional healers, Elders and other cultural healers.

Outcome 3.2: Equality of mental health outcomes is achieved across the Aboriginal and Torres Strait Islander population

Rationale: Groups vulnerable to mental health and related problems that require focused attention include, but are not limited to, members of the Stolen Generations; people living with disabilities and long-term health conditions; lesbian, gay, bisexual, transgender and intersex people; prisoners and young people in detention; and Elders.

Key strategies

1. Develop strategies to support the mental health and social and emotional wellbeing of:
2. Members of the Stolen Generations and their families.
3. Those with chronic health conditions and/or disabilities.
4. Lesbian, gay, bisexual, transgender and intersex people.
5. Prisoners and young people in detention.
6. Elders.
7. People with co-morbidities, including alcohol and other drug issues and mental health issues.
8. Foster partnerships between Aboriginal Community Controlled Health Services and prison health services to support the social and emotional wellbeing and meet the mental health needs of prisoners, with particular focus on those with cognitive disabilities, substance abuse disorders and mental health problems.
9. Support prisoners post-release, when the risk of recidivism, drug and alcohol misuse and suicide is high.
10. Develop national responses to Aboriginal and Torres Strait Islander people living with dementia that are consistent with the National Framework for Action on Dementia 2015-2019.
11. Integrate culturally competent mental health support services with the National Aboriginal and Torres Strait Islander Flexible Aged Care Program, community aged care packages, residential aged care and palliative care.

Example actions

• Promote holistic services for people with cognitive and developmental impairments and disabilities and mental illness, including through the National Disability Insurance Scheme.
• Co-locate and integrate drug and alcohol and mental health programs
• Encourage young people’s service providers to address issues of sexual identity.
• Assist elderly members of the Stolen Generations outside of institutional contexts to avoid re-activation of trauma from childhood institutionalisation.

Outcome 3.3: Mental health and related problems are detected at early stages and their progression prevented

Rationale: Mental health literacy helps people to recognise and provide initial help to a person with a mental health problem, including connecting them to appropriate treatment. It also encourages help seeking behaviour. Sensitive enquiry into a person's life circumstance is enhanced, in appropriate settings, by culturally adapted mental health screening tools to improve the detection of psychological distress and trauma at an early stage and age to help prevent mental illness, suicidal ideation and substance use disorders.

Key strategies

• Ensure communities and families have a better understanding of the importance and role of mental health services and the impact of mental illness including by encouraging natural helpers and help-seeking behaviour.
• Increase mental health literacy and trauma sensitivity in front-line services, particularly those that work with Aboriginal and Torres Strait Islander children and young people.
• Work in partnership with Aboriginal Community Controlled Health Services to develop a culturally appropriate targeted communications strategy, including mental health promotion materials, for adaptation by communities to raise mental health literacy and de-stigmatise mental health conditions.
• Support Aboriginal Community Controlled Health Services, general practitioners and frontline services to detect people at risk of mental health problems and make appropriate referrals.
• Develop a suite of culturally adapted, validated social and emotional wellbeing and mental health screening tools for use across the life course by Aboriginal Community Controlled Health Services and general practitioners.
• Implement the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy 2013.
• Support access to cultural liaison officers and language interpreters.

Example actions

• Identify and support natural helpers by enabling them to undertake mental health literacy training and other forms of gatekeeper training.
• Promote mental health literacy and reduce stigma.
• Adapt digital pathways to the mental health system and promote culturally appropriate self-help options in the digital mental health gateway.
• Primary Health Networks work in partnership with Aboriginal Community Controlled Health Services, general practitioners and specialist services to develop and promote clear, culturally and age appropriate referral pathways for those at risk of mental health problems and mental illness, substance abuse disorders, and suicide.
• Develop and use validated developmental screening tools as part of child health checks.

Outcome 4.1: Aboriginal and Torres Strait Islander people living with a mild or moderate mental illness are able to access culturally and clinically appropriate primary mental health care according to need

Rationale: There is a need to better integrate social and emotional wellbeing, mental health, substance abuse, suicide prevention, and social support services, including through services provided by Aboriginal Community Controlled Health Services, general practitioners and allied health professions across the mental health system.

Key strategies

1. Integrate mental health and other related areas services delivered by Aboriginal Community Controlled Health Services and other health providers, including cultural healers.
2. Develop, implement and review good practice models for service delivery with structured clinical decision-making tools to support consistent standards for diagnosis, treatment and rehabilitation. This should include the use of standardised outcome measures and auditing tools to assess the quality and outcomes from therapy as well as the provision for adequate supervision and support to all therapists and care management workers.
3. Explore culturally appropriate low intensity treatment pathways that can be delivered by Aboriginal Community Controlled Health Services. Complement these treatment options through culturally appropriate self-help options delivered through the digital mental health gateway.
4. Support general practitioners in undertaking assessments to ensure Aboriginal and Torres Strait Islander people are appropriately referred to services using Mental Health Treatment Plans.
5. Ensure access to general practitioner-prescribed mental health medications.
6. Integrate clinical and non-clinical services who work with children and young people including child and adolescent mental health services and headspace to better support their needs and reduce suicide.
7. Support and coordinate the data collections, measurement and evaluations required to inform system monitoring, accountability and service quality improvement.

Example actions

• Primary Health Networks work in partnership with Aboriginal Community Controlled Health Services to identify and aim to meet local needs gaps, including through wider partnership arrangements with residential treatment and supported accommodation facilities to integrate health and mental health care and social and cultural support both for ambulatory clients as well as those in residential facilities.
• Promote culturally appropriate screening for emotional and behavioural difficulties and trauma, particularly in children and young people.
• Provision of person-centred clinically and culturally appropriate primary mental health care by general practitioners and general population mental health services.
• Provision of care (inclusive of assessment, treatment and follow up) is undertaken in collaboration with mental health workers, significant family and/or community members, including Elders, traditional healers and/or cultural healers.
• Mental health needs assessments to account for key social issues such as housing, income and support networks, in addition to clinical needs, and referrals to appropriate social services when such services are not available as part of routine care within a single provider.
• Enhance opportunities for community/client participation.

Outcome 4.2: Culturally and clinically appropriate specialist mental health care is available according to need

Rationale: Access to culturally and clinically appropriate mental health care services should reflect the greater needs of Aboriginal and Torres Straits Islander people. Access should be enhanced by Primary Health Networks who commission local allied mental health professionals to provide psychological services, as well as by Medicare Benefits Schedule subsidised pathways through general practice referrals.

Key strategies

1. Establish social and emotional wellbeing teams in Aboriginal and Torres Strait Islander primary health care services (including Aboriginal Community Controlled Health Services) linked to Aboriginal and Torres Strait Islander specialist mental health services (see Appendix 3 for further information).
2. Ensure the required mix and level of specialist mental health services and workers, paraprofessionals and professionals required to meet the mental health needs of the Aboriginal and Torres Strait Islander population, including specialist suicide prevention services for people at risk of suicide (see Appendix 2 for an example).
3. Incorporate cultural competency in the professional standards and responsibilities of mental health professions within a social and emotional wellbeing framework.
4. Expand access to Focused Psychological Strategies and mental health professionals through the pooled mental health funding available to Primary Health Networks, and through supporting access to Medicare Benefits Schedule subsidised services.
5. Support and coordinate the data collections, measurement and evaluations required to inform system monitoring, accountability and service quality improvement.
6. Support access to cultural liaison officers and language interpreters.

Example actions

• Map existing regional and local services and workers, inclusive of mental health workers, counsellors, psychiatrists, traditional and cultural healers, registered psychologists, occupational therapists and accredited social workers against need and meet gaps as required.
• Promote links between Aboriginal Community Controlled Health Services and community mental health, alcohol and other drugs, primary health care, psychiatrists and other mainstream mental health services.
• Allocate available resources in a planned manner to achieve equitable access to psychological services for Aboriginal and Torres Strait Islander people.
• Provide effective post discharge follow-up for people who have self-harmed or attempted suicide.
• Evaluate dedicated specialist mental health care services where they exist (such as the Western Australian Statewide Specialist Aboriginal Mental Health Services) and study the feasibility of a national roll out.
• Protocols developed for services to help clients maintain links to family, community and other support systems.
• Employment of Aboriginal and Torres Strait Islander staff across, and at all levels of, the mental health system.
• Enhance opportunities for client participation in these actions.

Outcome 4.3: Effective client transitions across the mental health system

Rationale: A mental health client may use frontline services, primary services, specialist services, and support services. Developing and promoting clear pathways between these services is important for ensuring that the provision of care is continuous, person-centred and holistic care as clients transition across the system.

Key strategies

1. Primary Health Networks work in partnership with Aboriginal Community Controlled Health Services on a regional or other geographical basis to: identify and map relevant services and agencies; and develop, promote and regularly review culturally and clinically appropriate pathways between them – in particular, for the treatment of trauma and emotional and behavioural difficulties in children.
2. Coordinate and integrate mental health, social and emotional wellbeing, substance misuse, suicide prevention and social health services and programs to ensure clients experience seamless transitions between them.
3. Facilitate robust systems of communication between mental health services and programs, including moving towards shared use of digital records, utilising the My Health Record as appropriate.
4. Support access to cultural liaison officers and language interpreters.

Example actions

• Develop inter-agency protocols for admissions, referrals and discharge.
• Referral and discharge protocols are integrated and consistent among services providers.
• Cultural support (such as an Aboriginal and/or Torres Strait Islander mental health worker, family or community member, an Elder, traditional healer or cultural healer) is provided during admission.
  • Protocols developed to ensure the facilitation of client access to community support on return to community. Consider:
  • Cultural safety.
  • Linking into support from local Aboriginal organisations, inclusive of Aboriginal and Torres Strait Islander mental health workers, Elders, traditional healers and cultural healers.
  • Pharmaceutical issues.
• Shared case management planning and follow up.
• Facilitate regular planning meetings with Primary Health Networks, Aboriginal Community Controlled Health Services, mainstream mental health providers and support services.
• Provide opportunities for community/client participation. For example, create spaces for community/client involvement/feedback through social activities.
• Identify opportunities and develop innovative strategies such as the use of single care plans to support improved service integration and connect people with community based (non-health) services.

Outcome 5.1: That the human rights of Aboriginal and Torres Strait Islander people living with severe mental illness are respected

Rationale: Aboriginal and Torres Strait Islander people living with severe mental illness are entitled to protections as people with mental illness as provided by the 1991 United Nations' Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care; the 2006 United Nations Convention on the Rights of Persons with Disabilities; and equal protection under the 2012 Mental Health Statement of Rights and Responsibilities of Australia's National Mental Health Strategy.

Key strategies

1. Ensure access to culturally and clinically appropriate treatments, including with Elders, traditional healers, cultural healers and interpreters.
2. Ensure the social and emotional wellbeing of Aboriginal and Torres Strait Islander people with severe mental illness is supported, including within psychiatric hospitals and in supported accommodation facilities.
3. Develop culturally adapted assessment and treatment information options for those with severe mental illness and their families and carers.

Example actions

• Provide treatment in line with the rights of persons with mental illness, including in psychiatric hospitals and in supported accommodation facilities.
• Examine ways that the social and emotional wellbeing of Aboriginal and Torres Strait Islander people with severe mental illness can be supported. Consider:
  • Cultural safety in psychiatric hospitals and supported accommodation facilities.
  • Linking into support from local Aboriginal organisations, inclusive of Aboriginal and Torres Strait Islander mental health workers, Elders, traditional healers and cultural healers.
  • Pharmaceutical needs.
  • Shared case management planning and follow up.
• Minimise the use of coercive treatments, seclusion and restraint.
• Provide opportunities for community/client participation in decision making around their treatment and care.

Outcome 5.2: Aboriginal and Torres Strait Islander people in recovery are able to access support services in an equitable way, according to need, within a social and emotional wellbeing framework

Rationale: Those who experience severe mental illness often require on-going support to maintain connections to their families and communities among other social and emotional wellbeing domains. Enabling such to live in communities and close to their families is important and aligns with recovery-oriented approaches to mental health service provision. Person-centred approaches are critical to recovery, which aims to maximize individual control and self-management of mental health and wellbeing, in part by assisting families to understand the challenges and opportunities arising from their family member's experiences.

Key strategies

1. Assist young people up with mental illness to meet their educational and/or vocational goals and maintain friendship networks.
2. Support adults in recovery to maintain employment and family responsibilities.
3. Support culturally appropriate rehabilitation for Aboriginal and Torres Strait Islander people with severe mental illness.
4. Ensure recovery is facilitated within a social and emotional wellbeing framework.
5. Support people with mental illness, their families and carers to live in communities including through community mental health support programs.

Example actions

• Provide culturally adapted information about assessment and treatment options to those in recovery and their families and carers.
• Enhance services delivered by mental health nurses in community settings.
• Empower client participation in decision making about their support needs.

Outcome 5.3: Aboriginal and Torres Strait Islander people living with psychosocial disability are able to access the National Disability Insurance Scheme and other support services in an equitable way, according to need, and within a social and emotional wellbeing framework

Rationale: Fragmentation of care is particularly problematic for people living with a psychosocial disability as they often have to navigate a complex system across multiple providers. The National Disability Insurance Scheme provides opportunities to access integrated planning and coordinated care and supports which are culturally appropriate. The importance of extended family and community networks for Aboriginal and Torres Strait Islander people has implications for the way in which the role of carer is viewed and the needs of Aboriginal and Torres Strait Islander carers have traditionally not been well represented by carer organisations.

Key strategies

1. Ensure that the National Disability Insurance Scheme has Aboriginal and Torres Strait Islander people as a priority group and that providers are capable of working in a culturally competent manner and within a social and emotional wellbeing framework. Where appropriate services do not exist, support Aboriginal and Torres Strait Islander businesses to provide the services.
2. Ensure that carer respite and other support programs have Aboriginal and Torres Strait Islander carers as a priority group and that they have reach into communities.
3. Determine how the social and emotional wellbeing of people with a psychosocial disability can be supported.

Example actions

• Enhance regionally based clinical assessment arrangements for people with psychosocial disability to help match people to the services which best meets their needs.
• Empower client participation in decision making about their support needs under the National Disability Insurance Scheme.

In March 2008, the then Australian Government and Opposition, and most Australian State and Territory governments, committed to the Close the Gap Statement of Intent. It included the following specific commitment:

To developing a comprehensive, long-term plan of action, that is targeted to need, evidence-based and capable of addressing the existing inequities in health services, in order to achieve equality of health status and life expectancy between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians by 2030.⁶³

The launch of the National Aboriginal and Torres Strait Islander Health Plan 2013-2023 (NATSIHP) marked the fulfillment of a major part of this commitment. However, more is needed if mental health needs are to be fully addressed. As the 2015 NATSIHP Implementation Plan, developed in partnership with Aboriginal and Torres Strait Islander health leadership bodies, states:

…comprehensive responses to mental health and social and emotional wellbeing and alcohol and other drug use are set out in the National Strategic Framework for Aboriginal and Torres Strait Islander Peoples' Mental Health and Social and Emotional Wellbeing, the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy, and the Aboriginal and Torres Strait Islander Peoples' Drug Strategy 2014-2019 (under development). It is anticipated that these and other strategies will complement the focus on health in this plan.⁶⁴

This Framework therefore is an integral part of any actions to close the health gap between Aboriginal and Torres Strait islander people and non-Indigenous people.

Further, this Framework informs priority actions for improving Aboriginal and Torres Strait Islander mental health and suicide prevention, including those within the Fifth National Mental Health and Suicide Prevention Plan. This work must occur in partnership with Aboriginal and Torres Strait Islander mental health and related area leadership bodies.

Monitoring and accountability

Monitoring progress and evaluating outcomes from actions implemented as a consequence of this Framework is vital to inform the evidence base of what works and what doesn't work. Any monitoring framework should be developed under the leadership of, and in partnership with, Aboriginal and Torres Strait Islander leadership bodies. Indicators should draw on Aboriginal and Torres Strait Islander understandings of how to measure mental health and social and emotional wellbeing as well as general population measures including those from the Mental Health Management Performance Framework used to measure the performance of the mental health system.⁶⁵

The above could include indicators to measure:

• Social and emotional wellbeing.
• Mental health problems and mental illnesses.
• The determinants of mental health problems and mental illnesses.
• The performance of the mental health system overall.
• Specific indicators for services disaggregated for Aboriginal and Torres Strait Islander peoples.

Such measures should be drawn from, or incorporated into, the Overcoming Indigenous Disadvantage Framework that measures progress towards the COAG Closing the Gap targets and progress under the COAG Closing the Gap framework.

Strategy 1C of the 2015 NATSIHP Implementation Plan identifies that the Australian Government, the National Aboriginal and Torres Strait Islander Leadership in Mental Health, and the Aboriginal and Torres Strait Islander Mental Health and Suicide Prevention Advisory Group have a monitoring role for the implementation of this Framework. Progress will be reported every two years in line with the release of the Aboriginal and Torres Strait Islander Health Performance Framework.⁶⁶

Appendix 1: A Statistical Snapshot of Aboriginal and Torres Strait Islander Mental Health and Related Areas and Service Use

In the 2016 Census, about 650,000 respondents identified as Aboriginal and/or Torres Strait Islander, about 100,000 more than in the 2011 Census.⁶⁷ At time of writing, the Australian Bureau of Statistics (ABS) has not issued an adjusted population estimate to account for potential under counting. However, based on 2011 Census data, it has projected that the Aboriginal and Torres Strait Islander population would be 745,000 persons in June 2016.⁶⁸

Across a range of indicators, Aboriginal and Torres Strait Islander mental health outcomes are considerably poorer than those of their non-Indigenous peers:

• The Longitudinal Study of Indigenous Children showed that 23 per cent of Aboriginal and Torres Strait Islander children were at high risk of clinically significant emotional and behavioural difficulties in 2012.⁶⁹
• In the 2014-2015 ABS National Aboriginal and Torres Strait Islander Social Survey, (Social Survey), 33 per cent of adult respondents had high/very high levels of psychological distress: 2.6 times that of as non-Indigenous adults. There was also a significant six percentage point increase in those reporting high/very high levels of psychological distress between 2004-2005 (27 per cent) and 2014-2015.⁷⁰
• Also in the Social Survey, 29 per cent of respondents aged 15 years and over reported having a long-term mental health condition. Of those aged 18 years and over reporting a mental health condition, the main types of conditions were: depression (72 per cent); anxiety (65 per cent; behavioural or emotional problems (25 per cent; and harmful use of drugs or alcohol (17 per cent).⁷¹
• Suicide accounted for over 1 in 20 Aboriginal and Torres Strait Islander deaths in 2015 compared to just under 1 in 50 non-Indigenous deaths. From 2011 to 2015, suicide was the leading cause of death for Aboriginal and Torres Strait Islander persons between 15 and 34 years of age, and was the second leading cause for those 35-44 years of age. These are rates between two and four times those of non-Indigenous Australians in age groups between 15 and 44.⁷²

The 2015-2016 Aboriginal and Torres Strait Islander health services Online Services Report collated data from 277 organisations funded by the Australian Government to provide primary health care, maternal and child health care, social and emotional wellbeing services, and substance-use services to Aboriginal and Torres Strait Islander peoples. They included 204 primary health care services operating from 368 sites;⁷³ of which 136 services were Aboriginal Community Controlled Health Services.⁷⁴ The 204 services reported about 365,000 Aboriginal and Torres Strait Islander clients - about half of the total Aboriginal and Torres Strait Islander population.⁷⁴

Ninety-three organisations were funded by the Commonwealth Department of the Prime Minister and Cabinet to deliver social and emotional wellbeing services across 164 sites. They employed 216 counsellors who had, collectively, about 18,900 clients.⁷⁶

Studies have found that for Aboriginal and Torres Strait Islander peoples ‘access to service is critical and, where Aboriginal Community Controlled Health Services exist, the community prefers to and does use them.⁷⁷ With appropriate resources, an Aboriginal Community Controlled Health Service is able to implement a culturally competent and comprehensive primary health care model founded on the concept of social and emotional wellbeing. However, in the 2015-2016 Online Service Report, of the 204 primary health care services including Aboriginal Community Controlled Health Services, 54 per cent reported gaps in mental health/social and emotional wellbeing services: the most widely reported gap and consistently so since services were first asked to identify service gaps in 2012-2013 Around half also reported alcohol, tobacco and other drugs and youth services as gaps.⁷⁸

Aboriginal and Torres Strait Islander peoples have lower access to primary mental health services, or use those available at lower rates than might be expected, given their significantly greater mental health needs:

• In the 2012-2013 ABS Australian Aboriginal and Torres Strait Islander Health Survey only about one in four (27 per cent) of adults with high/very high levels of psychological distress had seen a health professional in response in the previous four weeks.⁷⁹
• Over 2010-2015, general practitioners managed mental health related problems for Aboriginal and Torres Strait Islander patients at 1.2 times the rate for other Australians.⁸⁰
• In 2014-2015, 10 per cent Aboriginal and Torres Strait Islander peoples used Medicare-subsidised mental health care services, (provided by consultant psychiatrists, clinical psychologists, general practitioners and allied health professionals) compared to 9 per cent of non-Indigenous people.⁸¹

Because of Aboriginal and Torres Strait Islander peoples' lower access to, or use of, primary mental health care according to need, they are overrepresented in other parts of the health and mental health system:

• In the two years to June 2015, the hospitalisation rate for mental health issues for Aboriginal and Torres Strait Islander males was 2.1 times the rate for non-Indigenous males, and the rate for Indigenous females was 1.5 times the rate for non-Indigenous females.⁸²
• In 2014-2015, Aboriginal and Torres Strait Islander peoples used state and territory-based community mental health services at 4 times the rate of non-Indigenous peoples.⁸³

Appendix 2: Case Studies

The following four case studies are intended to demonstrate the kinds of responses services might adopt within the broader context of an overall response to the social and emotional wellbeing of the person, including their mental health needs.

Case study 1: Older Person

Marjorie, a 76-year old, presented at her general practitioner (GP) with the following symptoms and issues:

• Recently widowed and grieving.
• Feeling overwhelmed by being single and living at home.
• Children living in other cities with Marjorie feeling she did not want to burden them.
• Feeling isolated and alone.
• Diagnosed with cancer.
• Deep desire to spend time on country and die on country.

Encouraged by her GP working with her local Aboriginal Community Controlled Health Service (ACCHS), mental health services and other agencies, Marjorie began to strengthen her social and emotional wellbeing to better cope with her bereavement and illness. How these agencies interacted to support her is illustrated in the table below, with mental health services highlighted in the green shaded areas.

Case study 2: Mother and Child

Jim, a nine year old, presented at an ACCHS with his mother Anna, and with the following presentations:

• Physically injured as a result of school violence caused by ongoing bullying, mentally traumatised.
• Emotional and behavioural issues and speaking with a stutter.
• Being bullied at school resulting in truancy and poor performance.
• Unresolved grief at the suicide of his older brother a year previously.
• Start of self-harming behaviour.

Anna, too, presented with symptoms of unresolved grief and trauma. She reported feeling isolated and needing support to raise her son as she is by herself. Encouraged by the ACCHS, both Jim and Anna sought support and were referred to a range of services as is illustrated in the table below, with the role of mental health services highlighted in the green shaded areas.

Case study 3: Adult Male

John, a 25-year old male, presented at an ACCHS with the following issues and symptoms:

• Chronic cannabis smoker.
• Poor health.
• Homeless, living in public parks.
• Feeling disconnected from his family, community and culture.
• Trauma as a result of continued exposure to violence.
• Recently arrested for assault.
• Hearing voices in his head.

Encouraged by the ACCHS, John began treatment within the mental health system. This included being diagnosed with schizophrenia and receiving help on that basis. He also worked with a range of agencies in a holistic manner to stabilise his life and boost his sense of identity as an Aboriginal man and his connection to family, community and culture. This is illustrated in the table below with mental health services highlighted in the green shaded areas.

Case study 4: Adult Female

Sarah, 43 years old, presented at an Aboriginal women's refuge with the following history:

• Forcibly removed from her Aboriginal family as a child and raised by a non-Indigenous family.
• Suffered racism and felt alienated in the family and at school.
• Her first husband left her after ten years took her three children and denied her contact with them.
• A twenty-year period of alcoholism with a non-Indigenous husband who was violent and abusive.

She presented with the following symptoms and issues:

• Homeless and unemployed.
• Occasionally seeing her violent husband.
• Managed to stop drinking and was in reasonably good physical health.
• Complex symptoms of psychological distress including grief and loss, sadness and low mood.
• Hearing the voices of her ancestors.
• Post Traumatic Stress Disorder.

Encouraged by the refuge, Sarah began a journey to wellbeing that involved working with a range of agencies in a holistic manner. How these agencies interacted is illustrated in the table below, with mental health services highlighted in the green shaded areas.

Appendix 3: Social and Emotional Wellbeing Teams⁸⁴

Where possible, Aboriginal and Torres Strait Islander client management and treatment should be provided by a social and emotional wellbeing team

Social and emotional wellbeing teams may include social and emotional wellbeing workers, mental health workers, psychologists, Aboriginal and Torres Strait Islander mental health workers and occupational therapists depending on the need of any given population group. Teams should have the capacity to work with, and make appropriate referrals for, children with symptoms of distress and trauma as illustrated in Diagram 3.

Diagram 3: Potential Reach of a Social and Emotional Wellbeing Team

In 2009, the Aboriginal Medical Services Alliance Northern Territory (AMSANT) proposed a model for integrating alcohol and other drug, community mental health and primary health care in Aboriginal Medical Services in the Northern Territory. This included appropriate needs based population workforce ratios for psychologists and psychiatrists to work with social and emotional wellbeing teams that for a community of 1500 people comprises: four Aboriginal Family Support Workers (including at least one of each gender) with one position identified as a manager; two skilled counsellors able to deliver cognitive behavioural therapy; and two of either a mental health nurse or registered mental health worker. That is, in addition to the core primary health care clinical staff of two general practitioners, six nurses and eight Aboriginal and Torres Strait Islander Health Workers.⁸⁵

By the workforce ratio, psychologists would be based zonally with one for every 1500 people. They would provide supervision to counsellors and see those with more complex situations, including addiction, interpersonal violence and complex problems in young people. There would be one psychiatrist for every 8,000 people, based in regional centres.Modelling was also undertaken for Aboriginal and Torres Strait Islander populations of 750 and lower.⁸⁶

Appendix 4: Consultation and Writing Process

• While taking the 2004 Social and Emotional Wellbeing Framework as a starting point, this Framework also incorporates the views of over 30 Aboriginal and Torres Strait Islander communities, and over 180 organisations, service providers and expert groups who were consulted as a part of a national consultation on the renewal of the Framework.⁸⁷ The main messages from the process were that this Framework should:
• Be non-prescriptive and inclusive of the diverse life experiences of contemporary Aboriginal and Torres Strait Islander people.
• Include an across the life course approach.
• Be strengths based and incorporate healing.
• Be reflective of the 2004 Social and Emotional Wellbeing Framework's implementation.
• Be useful.⁸⁸

The Social Policy Research Centre, University of New South Wales in partnership with the Nulungu Research Institute, University of Notre Dame Australia were engaged by the then Department of Health and Ageing to undertake the first phase of the project.

A review of policies and programs in Australia and international literature relating to Aboriginal and Torres Strait Islandersocial and emotional wellbeing was conducted. Extensive consultations were undertaken and included workshops, face to face meetings and teleconferences.

A cross-jurisdictional Social and Emotional Wellbeing Framework Renewal Working Group guided the renewal of the Framework. In addition to a carer representative and a consumer representative, the Working Group included representatives from the following:

• Federal and State/Territory Government Departments.
• National Sorry Day Committee.
• National Stolen Generations Alliance.
• National Aboriginal and Torres Strait Islander Health Standing Committee.
• National Aboriginal Community Controlled Health Organisation.
• Aboriginal and Torres Strait Islander Mental Health and Suicide Prevention Advisory Group (ATSIMHSPAG).

A group of writers led by Professor Pat Dudgeon and including Mr Christopher Holland completed the Framework over 2014-2017. Expert input and advice was provided by ATSIMHSPAG – an advisory body to the then Minister for Indigenous Health and Minister for Mental Health and now the Minister for Indigenous Affairs, the Minister for Health and the Minister for Indigenous Health. This body comprised:

• Professor Tom Calma AO (Co-chair) (2013-2016)
• Mr Tom Brideson (2013-2016)
• Ms Lisa Briggs (2013-2014)
• Ms Adele Cox (2013-2016)
• Mr Gerry Georgatos (2013-2016)
• Ms Katherine Hams (2013-2016)
• Mr Rod Little (2013-2014)
• Dr Marshall Watson (2013-2016)
• Professor Ernest Hunter (2013-2014)
• Assoc. Professor Peter O’Mara (2013-2016)
• Mr Charles Passi (2013-2014)
• Mr Ashley Couzens (2013-2014)
• Ms Valda Shannon (2013-2014)
• Ms Victoria Hovane (2013-2016)
• Aunty Lorraine Peeters (2013-2014)
• Ms Donna Ah-Chee (2015-2016)
• Ms Marion Scrymgour (2015-2016)
• Mr Aaron Stuart (2015-2016)
• Ms Gayili Marika-Yunupingu (2015-2016).

Expert advice and guidance was also provided by:

• Professor Helen Milroy
• Dr Graham Gee
• Professor Ian Ring
• Ms Kerrie Kelly.

The document was finalised by ATSIMHSPAG in consultation with the Australian Government.

1. Swan P, and Raphael B, ‘Ways forward': National Consultancy Report on Aboriginal and Torres Strait Islander Mental Health. AGPS, Canberra, 1995.
2. Social Health Reference Group, Social and Emotional Well Being Framework: A National Strategic Framework for Aboriginal and Torres Strait Islander Mental Health and Social and Emotional Wellbeing 2004-2009, AGPS, Canberra, 2004.
3. Raven M, Hovan V, Kamara M, Katz I, Gorring B, Kinnane S, and Griffiths A, Development of a renewed National Strategic Framework for Aboriginal and Torres Strait Islander Peoples' Mental Health and Social Emotional Wellbeing (2004-2009), Social Policy Research Centre, University of New South Wales, prepared for the Department of Health and Ageing, Sydney, 2013.
4. Australian Government, Australian Government Response to ‘Contributing Lives, Thriving Communities – Review of Mental Health Programmes and Services, Commonwealth of Australia, Canberra, 2015.
5. Australian Institute of Health and Welfare, Australian Burden of Disease Study: Impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2011. Australian Burden of Disease Study series no. 6. Cat. no. BOD 7. AIHW, Canberra, 2016, p.viii.
6. Australian Government, National Aboriginal and Torres Strait Islander Suicide Prevention Strategy, Department of Health and Ageing, Canberra, 2013, p.8 (Action Area 6).
7. Australian Government, National Aboriginal and Torres Strait Islander Peoples' Drug Strategy 2014 - 2019, Intergovernmental Committee on Drugs, Canberra, 2016, p.4 (Principles).
8. Australian Government, Aboriginal and Torres Strait Islander mental health services, PHN Primary Mental Health Care Flexible Funding Guidance, Department of Health, Canberra, 2016, p.3.
9. See n.4.
10. Gee G, Dudgeon P, Schultz C, Hart A, and Kelly K, ‘Social and Emotional Wellbeing and Mental Health: An Aboriginal Perspective'. Chapter 4, in Dudgeon P, Milroy M, and Walker R(eds.), Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice – Revised Edition, Commonwealth of Australia, Canberra, 2014, p.55.
11. As above, p.58.
12. As above, p.58.
13. As above, p.57.
14. As above, p.61.
15. As above, p.62
16. As above, p.63.
17. Australian Government, National Aboriginal and Torres Strait Islander Health Plan 2013 - 2023, Department of Health, Canberra, 2013, p.9.
18. Zubrick S, Shepherd C, Dudgeon P, Gee G, Pardies Y, Scrine C, Walker R, ‘Social Determinants of Social and Emotional Wellbeing' in Dudgeon P, Milroy M, and Walker R (eds.), Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice – Revised Edition, Commonwealth of Australia, Canberra, 2014, pp.93-94; 99-104.
19. Australian Bureau of Statistics, ‘Psychological Distress' Australian Aboriginal and Torres Strait Islander Health Survey, First Results, 2012, ABS cat. no. 4727.0.55.001, 27/11/13. Published online: www.abs.gov.au/ausstats/abs@.nsf/ Lookup/9F3C9BDE98B3C5F1CA257C2F00145721?opendocument [Verified 15/7/17].
20. See n.18.
21. See n.2, p.3.
22. Close the Gap Clearinghouse, Strategies and practices for promoting the social and emotional wellbeing of Aboriginal and Torres Strait Islander people, Resource Sheet no. 19, Australian Institute of Health and Welfare, Canberra, and Australian Institute of Family Studies, Melbourne, 2013.
23. As above.
24. See n.18, pp 99 - 106.
25. Baldry E, Dowse L, and Clarence M, People with intellectual and other cognitive diability in the criminal justice system, University of New South Wales, Sydney, 2012.
26. Australian Government, Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013-2023, Commonwealth of Australia, Canberra, 2015, p.53.
27. Australian Health Ministers Conference, National Mental Health Policy 2008, Commonwealth of Australia, Canberra, 2009, p.13.
28. As above, p.30.
29. Kelly K, Dudgeon P, Gee G and Glaskin B, Living on the Edge: Social and Emotional Wellbeing and Risk and Protective Factors for Serious Psychological Distress Among Aboriginal and Torres Strait Islander People, Discussion Paper No. 10, Cooperative Research Centre for Aboriginal Health, Darwin, 2010.
30. See n.28.
31. Health Innovation network, What is person centred care and why is it important? Health innovation network, South London, 2016, p.1.
32. O'Halloran P, About Psychosocial Disability and the NDIS, Introduction to the Concept of Holistic Psychosocial Disability Support, Department of Human Services, Canberra, 2014. http:// www.ndis. gov.au/release-mental-health-papers [Verified 10 December 2015].
33. Australian Health Ministers Advisory Council, A National Framework for Recovery Oriented Mental Health Services, Commonwealth of Australia, Canberra, 2013.
34. Robertson D, Build your Resilience, Hodder Education, London, 2012 (Introduction).
35. World Health Organization, What are the Social Determinants of Health?, 2017. Published online: http://www.who.int/ social_determinants/sdh_definition/en/ [Verified 13/7/17].
36. Armstrong S, Buckley S, Lonsdale M, Milgate G, Bennetts Kneebone L, Cooke L, and Skelton F, Starting School: A Strengths based approach towards Aboriginal and Torres Strait Islander Children, Department of Families, Housing, Community Services and Indigenous Affairs, Canberra, 2012.
37. World Health Organization, ICD-10 Version: 2016, 2016. Published onl online: http://apps.who.int/classi cations/icd10/ browse/2016/en#/F10-F19 [Verified 13/7/17].
38. Atkinson J, Nelson J, Brooks R, Atkinson C, Ryan K, ‘Addressing Individual and Community Transgenerational Trauma', Chapter 17, in Dudgeon P, Milroy H and Walker R (eds.) Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice – Revised Edition, Commonwealth of Australia, Canberra, 2014.
39. Heffernan E, Andersen K, Dev A, et al, Prevalence of mental illness among Aboriginal and Torres Strait Islander people in Queensland prisons, Medical Journal of Australia, 2012; 197 (1): 37-41.
40. Osborne K, Baum F, Brown L, What works? A review of actions addressing the social and economic determinants of Indigenous Health. Issues paper number 7 produced for the Closing the Gap Clearinghouse. Australian Institute of Health and Welfare, Canberra, and the Australian Institute of Family Studies, Melbourne, 2013.
41. As above.
42. See n.17, p.8.
43. Australian Health Ministers' Advisory Council, Aboriginal and Torres Strait Islander Health Performance Framework 2017 Report, Department of the Prime Minister and Cabinet, Canberra, 2017, p.27.
44. Australian Human Rights Commission, National Anti-Racism Strategy, AHRC, Sydney, 2012.
45. As above.
46. Australian Health Ministers' Advisory Council, Cultural Respect Framework for Aboriginal and Torres Strait Islander Health 2016 -2026, AHMAC, Canberra, 2016.
47. As above.
48. See n.4.
49. As above.
50. Moffit T, Arsenault L, Belnsky D, Dickson N, Hancox R, et al., ‘A Gradient of Childhood Self- control Predicts Health, Wealth and Public Safety', Proceedings of The National Academy of Sciences of the United States of America, February 15, 2011, vol 108 no. 7.
51. Jacobs J, Agho K, Raphael B, ‘The prevalence of potential family life diffiulties in a national longitudinal general population sample of Australian children', Family Matters No. 90, 2012.
52. Australian Institute of Health and Welfare, Child protection Australia 2015-16, Child Welfare series no. 66. Cat. no. CWS 60, AIHW, Canberra, 2017, pviii.
53. As above, p.28.
54. Anda R, Felitti V, Walker J, Whitfield C, Bremner J, Perry B, et al., ‘The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology', European Archives of Psychiatry and Clinical Neuroscience 256(3): 174-86, 2006.
55. See n.50.
56. See n.4.
57. World Health Organization, Depression, 2017. Published online:http://www.who.int/topics/depression/en/ [Verified 7 July 2017].
58. Atkinson J, Trauma-informed services and trauma-specific care for Indigenous Australian children, Resource sheet no. 21, produced for the Closing the Gap Clearinghouse, Australian Institute of Health and Welfare, Canberra, Australian Institute of Family Studies, Melbourne, 2013.
59. Bainbridge R, McCalman J, Clifford A and Tsey K, Cultural competency in the delivery of health services for Indigenous people, produced for the Closing the Gap Clearinghouse. Australian Institute of Health and Welfare, Canberra, and the Australian Institute of Family Studies, Melbourne, 2013.
60. National Aboriginal Community Controlled Health Organisation, Definitions, 2015. Published online: http:// www.naccho.org.au/aboriginal-health/definitions/ [Verified 7/7/17].
61. Hayman N, White N, and Spurling G, ‘Improving Indigenous patients' access to mainstream health services: the Inala experience', Medical Journal of Australia, 2009; 190 (10): 604-606.
62. Australian institute of Health and Welfare, National Mental Health Performance Framework (KPIs for Australian Public Mental Health Services: PI 10 – Comparative area resources, 2015 – Health, Standard 19/11/2015). Published online: http://meteor.aihw.gov.au/content/index.phtml/itemId/584825 [Verified 14/7/17].
63. Close the Gap Campaign Steering Committee, Close the Gap Statement of Intent, Australian Human Rights Commission, Sydney, 2008.
64. See n.17, p.8.
65. See n.62.
66. See n.17, pp.12-13.
67. Australian Bureau of Statistics, 2016 Census shows growing Aboriginal and Torres Strait Islander population (Media Release), 27/6/17. Published online: http:// www.abs.gov.au/ausstats/ [Verified 13/7/17].
68. Australian Bureau of Statistics, Estimates and projections, Aboriginal and Torres Strait Islander Australians, 2001 to 2026, ABS cat. no. 3238.0. ABS, Canberra, 2014. Published online: http://www.abs.gov.au/ausstats/abs@.nsf/ mf/3238.0 [Verified 13/7/17].
69. Australian Health Ministers' Advisory Council, Aboriginal and Torres Strait Islander Health Performance Framework 2017 Report, AHMAC, Canberra, 2017, p.77.
70. As above p.76.
71. As above, p.77.
72. Australian Bureau of Statistics – ‘Intentional Self-harm in Aboriginal and Torres Strait Islander People', Causes of Death, Australia, 2015, ABS cat. no.3303.0, 2016. Published online: www.abs.gov.au/ausstats/abs@.nsf/Lookup/by% 20Subject/3303.0~2015~Main%20Features~Intentional% 20self-harm%20in%20Aboriginal%20and%20Torres% 20Strait%20Islander%20people~9 [Verified 7//7/17].
73. Australian Institute of Health and Welfare 2017. Aboriginal and Torres Strait Islander health organisations: Online Services Report—key results 2015-16. Aboriginal and Torres Strait Islander health services report no. 8. Cat. no. IHW 180., AIHW, Canberra, p.19.
74. As above, p.8.
75. As above, p.31.
76. As above, p.54.
77. Panaretto K, Wenitong M, Button S and Ring I, ‘Aboriginal community controlled health services: leading the way in primary care' (2014) 200(11) Medical Journal of Australia, 200 (11) 649.
78. See n.72, p.45.
79. See n.69, p.168
80. As above, p.77
81. As above.
82. As above, p.168
83. As above.
84. Schultz C, Walker R, Bessarab D, McMillan F, MacLeod J and Marriott R, ‘Interdisciplinary Care to Enhance Mental Health and Social and Emotional Wellbeing', Chapter 13, in Dudgeon P, Milroy H, and Walker R (eds), Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice – Revised Edition, Commonwealth of Australia, Canberra, 2014, 230 (Figure 13.2).
85. Aboriginal Medical Services of the Northern Territory, A model for integrating alcohol and other drug, community mental health and primary health care in Aboriginal Medical Services in the Northern Territory, AMSANT, Darwin, 2008.
86. As above.
87. Katz I, Raven M, Kinnane S, Griffiths A, Development of a renewed Framework for Aboriginal and Torres Strait Islander Social and Emotional Wellbeing, Report on Consultations October 2013, University of New South Wales, Social Policy Research Centre, Nulungu Research Institute, 2013, pp.43-50.
88. As above.