Episode 50: Mental health – building engagement with young Aboriginal and Torres Strait Islanders

Caroline West: Hello and welcome to the podcast. I'm Dr. Caroline West, and I'm a GP and a medical advisor for NPS MedicineWise. I'd like to start with an acknowledgement of country. I'm coming to you from Gadigal Country. I'd like to show my respects to elders past, present, and emerging. Now the last couple of years have been especially tough for young people living with mental health issues, disruption to work, social activities, education, chances to travel, see family. Today we're exploring mental health in young people from an Aboriginal and Torres Strait Island perspective. Joining me are three people with extensive experience in this area, two health professionals, and one with lived experience. I'd like to welcome to the show, Rebecca Davidson, Jamie Maney, and Sarah.

Sarah: Thank you.

Jamie Maney: Thanks, Caroline.

Rebecca Davison: Thank you.

Caroline West: Can I start off by getting each of you to introduce yourselves, tell us a bit about where you're from and what you do? Can we start with you, Rebecca?

Rebecca Davison: My name's Rebecca Davison, I'm a doctor doing GP training. I'm an aboriginal woman from Sydney, I grew up on Dharawal land and have connections to Dharawal and the Yuin people.

Caroline West: Thanks for being with us, Rebecca, that's great. Jamie, can you take us through your story?

Jamie Maney: Yeah. Hi, I'm a Wiradjuri Ngunnawal woman, I am a practice nurse at the Orange Aboriginal Medical Service, I'm also a sexual health coordinator.

Caroline West: Fantastic, I'll be looking forward to hearing your thoughts as we go through the podcast, thanks for being with us. And Sarah, to you.

Sarah: Hi, my name's Sarah, I am a young person, I'm a young Wiradjuri woman.

Caroline West: Fantastic. You're going to be talking to us today from the perspective of someone with lived experience.

Sarah: Yes, I am.

Caroline West: Fantastic, thanks for sharing with us today. I know the last couple of years have been pretty tough, that's what I alluded to in the intro there, and that's across the board and the community, but particularly for young people,] and particularly for young people in rural and remote regions, and also from Aboriginal and Torres Strait Islander backgrounds. Sarah, can you just take us through what it's been like for the last couple of years?

Sarah: Speaking directly as a young person who was really in a good place in their life when all this stuff started to happen, it's difficult, I would say. It's been very interesting seeing how isolated you are so far regionally, and how putting people in isolation in already isolated areas has such a negative effect on young people.

Caroline West: Yes, I have heard that many times, and that's been one of the very difficult challenges of this time.

If I can turn to you, Rebecca, you've been working with many Aboriginal young people during this time, what's your sense of it all at the moment?

Rebecca Davison: I think it's been difficult for everyone, and particularly young people. There's a lot of resilience that I've seen in the young adults and kids that have come to see me during this time, and I wonder if they even are aware of the impact that all the changes have had on their life and their mental wellbeing. They just come with the same normal issues or concerns that any young person would have, and they might not even realise how significant these last couple of years, how significant the impact has been on their wellbeing. They just know that something's different and hard.

Caroline West: I think you're right, I think it's going to be hard to know what the impacts will be until it plays out a little bit, because there's the short term impacts and then the longer term ones, of course. Jamie, what's your take?

Jamie Maney: I agree with Rebecca, a lot of resilience in these young children or young kids, and because it's become so normal for them, I don't think they even realise, like Rebecca said, the impacts that COVID has had on them, because the mental health stuff has just become normal for them. It doesn't even have a label with some of the kids, they don't even know it's happening.

Caroline West: That's really interesting. So, when you say it doesn't have a label, do you mean that just there's a pervasive sense of distress or stress, or how does that actually present?

Jamie Maney: They don't know what mental health is. It's not really until we start to unpack it that these kids realise that there is an issue.

Caroline West: Is it hard to even talk about mental health? Sarah, if I can go to you, what do you think it's like for young Aboriginal and Torres Strait Islander people when it comes to actually talking about how they're feeling or how they're going?

Sarah: I think a lot of it has to do with how open you and your immediate support network are. If you have had an experience where mental health was very openly spoken about in your household or in your community, I find it's probably a lot easier to talk about, but if you've grown up and had that experience of, "Everything's fine, get on with it, get over it," you're less likely to be able to reach out to a GP support service, a nurse, a friend, a family member. And in that case, if you haven't had that education, you haven't had that ability to know what mental health is, which a lot of people actually don't realise some of the things that they're experiencing are mental health related, then no one can actually put those into words and actually go and discuss it.

Caroline West: Yeah, it can be hard. Jamie, you talk to a lot of young people in your job as a nurse, and I imagine a lot of them are coming in for sexual health issues, but it gives you an opportunity about expanding the conversation. Do young people find it okay to talk about how they're traveling from a mental health perspective?

Jamie Maney: Some of them will open up, this all depends on the day and the approach, sometimes I can get them to open up, but sometimes I really struggle. Because there's so much stigma attached to the mental health, some of the kids are embarrassed to disclose what's happening atp home or inside themselves.

Caroline West: You've mentioned stigma, are there other things that really crop up as being challenges?

Jamie Maney: Why they're not disclosing? Big thing, particularly in Indigenous families. If we want to go back in history and talk about stolen generation, a lot of that talk goes on in the home when we're younger about, "They can come and take you. Docs will come and take you." And that goes back to those times. That's a massive barrier for our children not wanting to disclose to health professionals, because they're worried about someone coming in and taking them away from their parents.

Caroline West: That's incredibly important for us all to keep in mind, isn't it, when we're having those conversations?

Jamie Maney: Yeah.

Caroline West: And how do we change that so that we can build trust and so that young people can talk about what's important to them?

Jamie Maney: I think just being honest, hey? Honest and letting them know right from the jump that anything you say, anything you disclose, is not going to cause any harm or any trouble to your family. Because this stuff is embedded in us, and it's an automatic, "Oh, but what if I say this? What's going to happen? What's the repercussions?"

Caroline West: Rebecca?

Rebecca Davison: I would say it's not even just looking at their history, it's something that still is occurring. I think most, if not all, Aboriginal and Torres Strait Islander people would know someone who has been affected by removal of children from care and placed in out-of-home care. I certainly did growing up. It's still a very real fear

Caroline West: Rebecca, when you're actually talking to young people and you're trying to build that sense of engagement, because engagement is everything, really, isn't it, like without that, you can't get the next conversation happening and you don't get buy-in, and nobody wants to come back because they're not feeling comfortable, how do you as a GP actually build that engagement?

Rebecca Davison: I find chatting to them on a level that's comfortable for the patient, like in finding some common ground, whether it's about sport or hobbies or movies, that sort of thing, just anything to build a rapport, make them feel comfortable, so at the very least, they just come back to see you again, which could be the opportunity to then dive into their mental health, doing it gently and at the patient’s own pace and what they're comfortable with.

Caroline West: I know as health professionals, I'm a GP, and a lot of my training was about creating boundaries and barriers and not revealing too much of yourself, and I don't think we did enough about that idea of finding common ground and common interests. Jamie, how do you think we work on that side of things, to actually find the stuff in the middle that we can each relate to?

Jamie Maney: I think that's an area in which we could improve. Like Beck said, it's building that rapport, because we want those patients to come back. The way I usually approach those situations is take the clinic hat off, and engage with these patients as if they were a family member or an elder, but a bit more on a human level instead of so clinical.

Caroline West: Yeah. Sarah, nobody can see us on this podcast because it's obviously just the audio, but you're nodding your head there. You're obviously agreeing with what Jamie says, what are your thoughts?

Sarah: Yeah. Absolutely. I feel like any person, they don't have to be young, if they have ever gone into a clinic or a doctor's office or a hospital, anything like that, and they've been met with that, "Here's our list of credentials that you need to meet in order to be diagnosed or be considered or be thought of in these categories," with that very white coat, yes/no, it doesn't work. It puts up that protective barrier that young people have. They really just want someone to talk to them on a human level.

I think that's the most important thing, no matter what area of health it is, particularly with mental health and wellbeing, I think that they just want to be made a connection with. They want to feel important. They want to feel important for a few minutes, they want to know that the person that you're talking to cares about you, and in that moment, you are the most important thing to them.

Caroline West: I guess it's also about finding about somebody's life story, isn't it, like about family and where somebody's been raised, and the biggest sense of family in the community? Jamie, can you give us a sense of what you take someone through when you're trying to discover a bit more about someone, and to build that engagement?

Jamie Maney: Lose the judgment, that's my first thing. I do not judge anybody. I try to let the patient know, not that it's normal to be going through stuff in this space, but to let them know that they're not alone, because a lot of our community’s going through mental health, and trying to let the patient know that it's okay to speak, it's okay to engage and let people know what you're feeling.

Caroline West: The levels of distress are very high, I know that the Australian Institute of Health and Welfare, that pulls together some of the data on this, has shown that about two-thirds of young Aboriginal and Torres Strait Islander people are experiencing levels of psychological distress, which is very high. And it may be infused with their bigger experience of what they're going through in life meshed in with other health concerns, but that means that pretty well the majority of people that come in through the door to see you for some other matter are going to have a concern around mental health as well.

In terms of looking at some of the factors that may be protective for mental health conditions that actually help people, you've talked, all of you, about resilience, what are some of those factors, Rebecca, that you feel are protective that you also may explore in a consultation with someone?

Rebecca Davison: The connections that people have can be really protective. And working out who that support system for them is first up is really helpful I find. For many of the people that I see, it might not necessarily be their parents. It might be their or their grandma who's their confidant who's there for them. Things like being involved in sports and attending school or even part-time jobs. Those things that give someone a sense that they're worth something, that they're contributing, I think are really important as well in terms of being protective for someone's mental wellbeing.

Caroline West: If I can ask this of you, Jamie, if I can go to you. What do you think are some of those protective factors that help keep young people well?

Jamie Maney: Yeah, relationships, the important relationships. School friend circle. But yeah, those important relationships in their lives, whether that be a grandmother, a best friend. I find that elders play a big part in indigenous kids' lives, would be their Nan and Pop.

Caroline West: And a strong cultural identity is also central?

Jamie Maney: Yeah, absolutely. Unfortunately, some of our kids don't have that strong cultural identity, which in turn I find that those ones are our troubled children that have lost that connection to where they come from. That's their identity really can play a big part in these children going down a wrong path.

Caroline West: So from a health professional's perspective, it's obviously then incredibly important that we explore a sense of somebody's identity and what's important to them within their culture and their community, their connection, their relationships?

Jamie Maney: Yeah, absolutely. And just even by asking the question, because some of the kids they know the country in which they've come from, but it gives them a sense of like Sarah mentioned before, when us as professionals we ask those questions. Where are you from? Do you have any current connections to your country? Those patients feel like, yeah, you want to know, you really want to know. You have that genuine care.

Sarah: I'm going to echo what the professionals have said really. It's really important to have such a strong connection in those close relationships that you keep with yourself. For myself, I was very lucky to have quite a incredibly strong connection with my mom. So for me, she was that sort of grounding point. And my nana, they were two of the most important people to play a role in my mental health journey personally. Hearing everybody say school, I feel like when you hear that as a young person, you kind of laugh a little bit and you go, "Well it's not really that important."

But something that I noticed was when I would be in really dark places, I would miss school. I wouldn't go, I wouldn't want to go. There'd be no point in me going if I went, I was just going to go home early anyway. But I feel like once I sort of hit those later years of high school in particular and I started attending school more regularly, I was going at least four days a week. That was when I saw probably the biggest impact in my life, because I was finding these connections with people at school and they were constant people in your life, people who just don't go away.

Caroline West: Yeah. Having that sort of unconditional support and knowing somebody's always got your back is very powerful, isn't it? And if we sort go into this sense of the importance of having some of those difficult conversations. I know there are some conversations in mental health that are really hard to have, particularly around how somebody's really traveling about their risk, for example, or if they're having very dark thoughts, suicidal thoughts. And it's been shown that safety planning makes a really big difference to helping young people stay safe. What's your sense of the value of safety planning, Sarah?

Sarah: I think it's probably one of the most important things that you can discuss with a young person. I would take it back a step and remind young people that they're not in trouble for feeling these ways. I think when you start having those conversations about negative thoughts, intrusive thoughts, harmful thoughts, a lot of people get very defensive because they unconsciously think that, that's not a good thing. "I'm not supposed to be having these thoughts. They're going to judge me because I'm having these thoughts. I'm in trouble now." Removing that stigma of just because you're going through something at the moment and you're experiencing these negative things, you're not in trouble. Unfortunately it's something that you're going through and we want to help.

I think safety planning is such an interesting topic as someone who's been on the opposite side of it, been the person who's had to sit down and have those discussions in a more uncomfortable setting. I think it's something that needs to be approached in the way that Jamie speaks about. It's having a yarn, it's sitting there and it's talking about what you're comfortable with, what concerns you have, what the concerns of the people around you have. And having that integrated conversation between people who are experts and people who know what they're talking about, but also with yourself. And you need to feel comfortable and honest with who you are and with who they are and that connection, to be able to have a safety plan that's factual to who you are and one that is actually going to potentially save you.

Caroline West: Incredibly important to help keep young people safe, and gives you the opportunity to really look at some of the triggers and also some of the strengths, reasons to live, and a support network if things are not going well. It's great as a sort of template if you like, for how to have a discussion or a yarn as you say about some of those things. Never comfortable, but sometimes even acknowledging it's not comfortable can be fair enough. And when it comes to management, Sarah, obviously we talk a lot about this thing called shared decision-making where the person really has the central place in terms of deciding what's going to be done in terms of management. Because management could take all sorts of shapes and forms. How do we perhaps approach that and get young people's involvement with management from that perspective?

Sarah: I think it's having their input from day one. If a young person comes to you in a crisis situation or just wants to come and talk to you about not feeling so great, it's taking into account them at the forefront and it's having their input through every single decision that gets made. Whether or not it is, "Hey, you've said something to me that kind of concerns me a little bit. I think we should investigate this further. Is there a GP that you like to see?" Something as simple as that.

Opening the wavelengths for them to be able to bounce back with conversation and having their input and their AOK, if you will, is probably the most important part in having that shared decision-making. I don't feel like people who are having mental health difficulties or struggles or whatever they're feeling deep down, I don't think pushing information at them and just telling them, "Well now we're going to do this and now we're going to do this and now you have to do this." It's again, makes young people put those barriers up where they don't want to continue talking about it because they feel like they're at the forefront.

Caroline West: Yeah, that's a really good point.

Sarah: Mental health doesn't start when the crisis starts. It's not when someone comes to you, and they're at their riskiest, or they're at that point. Mental health starts with the really little stuff that are struggling to get out of bed, feeling a little bit crappy, feeling a little bit down on yourself, stuff like that. I think that we need to acknowledge that side of mental health, and not just the chaotic side when somebody is at their, quote unquote, worst, for a lack of a better word. When you're at your most concerning, shouldn't be when everybody starts to pull into action. I think it should be at the very, very start. And I think that's how we stop a lot of the mental health crises that affect young people.

Caroline West: When it comes to mental health, I'd like to go to you, Jamie, on this. It's so often those little things that pop up along the way that perhaps health professionals need to be aware of. You are seeing young people all the time. How do you approach mental health from that opportunistic point of view?

Jamie Maney: Most of the time they won't come in presenting for anything regarding the mental health. I usually touch on that subject throughout the consult. Yeah. Like I said, majority of the time they're coming in just for something acute, and it's not mental health. But I have a tendency of asking about are they feeling okay? Are they having silly thoughts, or feeling yucky? And a lot of the time, I'll get a yes. And then I sort of follow on from that. Yeah.

Caroline West: Because I guess that engagement takes time, doesn't it?

Jamie Maney: It sure does.

Caroline West: It's not done in one consult.

Jamie Maney: Yeah. Yeah.

Caroline West: Yeah. That trust.

Jamie Maney: Building that trust. And I find it does take a little bit to build that trust, but on the patient's return, when they start engaging, then you know that you're starting to make a bit of traction in regard to the patient. And then I sort of let them do the talking, reflecting back to what Sarah was saying in regard to allowing the patient to drive their healing, because they know what's going on inside their body. I think as professionals we can just help guide and support, but if they're not engaged in that journey, we don't engage the patient in that journey. Well, the steps won't be done on behalf of the patient for themselves.

Caroline West: Drive their healing, that's a very good way of summing it up, I think. And Rebecca, what's your sense of that with that drive their healing sentiment that Jamie's just talked about?

Rebecca Davison: Yeah, I totally agree with needing to get the patient on board in terms of their recovery plan and journey to wellness. It's not even about getting them on board, it is that shared decision-making. It's so important around mental health for the plan to be informed by the patient. They are the expert in themselves. They know what's going to work for them. I always give the patients the opportunity to tell me what they think is going to work, what's going to be helpful. When you were last well, what did that look like? What were you doing then? And from that shared decision-making perspective as well? I think, it was Jamie before saying, or Sarah, I can't remember, but not telling the person what to do. You have to do this, you have to do that. I think our job as health professionals is to give them all the options, show them the menu of what the potential things that could help include. The good and the bad on each of those, and let them decide what's going to work for them.

Caroline West: And that can include options that are lifestyle-based, community-based, perhaps pharmaceutical sometimes.

Rebecca Davison: Yeah. Definitely that the whole range. I always tell all the patients the range of options, from the psychotherapy, lifestyle strategies and interventions, and medications. I think so that they know what the spectrum is. I'll also give my opinion, and what I think would be appropriate. Medication isn't necessary for everyone. Sometimes it can be helpful for a short time. Sometimes people need to be on it longer. I'll give my opinion. But definitely letting them know all of the options.

Caroline West: And I guess if you have a chat to somebody, you've engaged with them, and you have a sense of their life, and you're worried about their safety, Jamie, how important is actually putting together a structured safety plan?

Jamie Maney: Very important, because in the event that our patients don't have anyone to reach out, or have someone to see in that instant when they really need to be seen, they could always refer back to a safety plan that has been done previously. We want to keep them alive in a sense. We want to give them some sort of self-worth. But a safety plan is quite important, because if their head isn't working, and they're feeling like they've got no option, well, yeah, they're going to take the not so... How would I say it? Yeah, they take the hard road, in a sense. Yeah. So safety planning is quite important, because like I said, we want to keep them here.

Caroline West: Yeah, it's one of those areas where that's of utmost importance, isn't it? Keeping young people safe.

Jamie Maney: Yes, yes.

Caroline West: Suicidal thoughts are very common when people have low mood, young people in particular. And as a GP myself, I've found that sometimes having those difficult conversations actually pay dividends, because somebody breathes out and goes, oh, thank goodness I'm allowed to talk about this. It's on the table. So I feel as though I can be supported with how I can manage this, rather than just keeping it to myself, keeping it a secret, keeping it from my family and friends. Yeah, it's very important.

Caroline West: Sarah, from the point of view of what you've discovered about yourself and your mental health, and what keeps you well, what have been some of those elements that help you there?

Sarah: I would say, the first thing that keeps me well is knowing that I'm not unwell. I'm not broken in any way, what goes on in my head isn't incurable, if you will. I think that was probably the first thing that happened. That was the step towards feeling more complete and feeling genuinely better, was having people who listened to me and reassured me that this wasn't something that I was never going to bounce back from. That if you can be nurtured and be supported, and you have that ability to take in all of that, and listen to the professionals as much as sometimes you don't feel like they're helping. That would probably be the first thing. And then the next was actually building my strategy of how I was going to push through some of the difficulties that I was facing at the time, which for myself was my incredibly low self-image.

I quite literally hated myself, in every sense of the word. So it was rebuilding my whole sense of self. So it was finding things that I genuinely enjoyed and wanted to do. And then just following on with, okay, well, now I actually feel confident a little bit. I feel like I'm not the worst thing. How can I now take that out into the world, and how can I continue to nourish that? And then it was finding other things to do with my time rather than just sitting there and wallowing or just sitting there in a pool of your own thoughts. It's finding those external things that I could physically get up and do. Those were probably the most nourishing things that I experienced.

Caroline West: I love that sense of nourish. That's a wonderful word to really capture this sense of empowerment with mental health in terms of your journey. Thank you so much, Sarah, for sharing your story. It's always hard talking about mental health for many people, and I really appreciate you sharing your story today, Sarah. It's wonderful.

Sarah: Thank you.

What are some of the other interventions, particularly from the lifestyle point of view, that you find have been really helpful with young people in their mental health, Jamie?

Jamie Maney: The connections, the eating right, the sleeping right, because it all adds to the decline in their mental health, if these areas aren't managed properly. Sleep is a big thing, especially in this day and age. The technology and whatnot. The kids tend to stay on the technology a lot. Their sleep hygiene is not very great. So all those areas are very, very important, and also plays an important part of keeping them safe as well.

Caroline West: Rebecca, what sort of things do you go through in terms of lifestyle?

Rebecca Davison: Talking about hobbies and finding out what the young person, what their likes and dislikes are, what they used to get joy out of if the joy is gone now. And kind of reminding them of those lighter times, I guess, I find it helpful to get them to write down the pleasant activities. So there's a list sitting there. Like Jamie said, when the brain's not working properly, it can be incredibly difficult to think, oh, what's a nice thing that's going to make me feel a bit better, now. If they've got a pre-written list, just look at the list, pick one and go for it. I always go through nutritious diet. The idea of sleep hygiene, not one person gets out of my consulting room without a discussion on sleep hygiene, because it affects so many. It can have such a flow on effect to everything else in your life. Whether you're sleeping too much or not sleeping enough. It has its own implications on your ability to function, and the brain's ability to concentrate.

As well as exercise, that idea of just any sort of physical activity. I find for myself as well, and feedback from other patients, is that connecting just to the land. Getting outside, walking on grass barefoot, going for a bush walk, it's rejuvenating. For some people, if they're not from the area. Like me, I'm a coastal girl living out here in Orange. Just getting back to the beach and being on country is another non-medicine, non-psychotherapy strategy that is really useful for people. And sometimes I think it's hard for us to know exactly what's missing, but we just feel a sense of discomfort or loss, and not really know why. So raising these things or giving suggestions of these things can be helpful. And then I find that the patients will come back with 10 better ideas than I had, because it starts their brain working and thinking about the things that they know will be nourishing for them.

Caroline West: Jamie, in terms of mental health and challenges for young Aboriginal and Torres Strait Islander people, what do you think are some of the things we need to keep in our mind?

Jamie Maney: Listen to really hear them, not just listen to respond. Really hear them, I think is most important. These kids or these patients, they want to be heard.

Caroline West: Very important to hear. Rebecca, from your perspective, what do you think we should be keeping in mind?

Rebecca Davison: There's a sense of a shared experience among Aboriginal and Torres Islanders, but it's also really important to remember that we're not all the same, and everyone's story and experience is different and individual for that person. We were talking before about connection to culture, which is incredibly important, but not all people might have that, because of events in the past that have happened. So like Jamie said, listening to hear, and in a nonjudgmental way.

Caroline West: And what about this, the sense of also focusing on not just what's making us unwell, but more focusing on what's keeping us well, Jamie?

Jamie Maney: Because that's what we do as professionals. We look at the bad stuff. Let's focus on the light instead of the dark.

Caroline West: And how do you talk to someone around that focusing on the light?

Jamie Maney: Well, whatever makes them feel lighter, whatever gives them joy, like Beck was saying earlier. Let's just focus on the good stuff rather than the bad stuff. And then that also aids in the healing as well. Because I find if you spend a lot of time focusing on the negative, you start to feed off that negative energy, that negative stuff. You start to live in that space. So focus on the positive stuff. Think something that makes you smile.

Caroline West: And Rebecca, how do you weave that into your consultations?

Rebecca Davison: We as a people and a culture are so resilient, just with everything that has happened with social determinants that are making some people's lives really difficult. It's nice to remind young people that they're surviving. They have 100% rate of getting through every difficult day, because they're still here. And they might come with some concerns about their behaviour, or feel bad around what they're using to help cope, but reframing that as still a strength of being resourceful enough to find something that keeps them surviving.

Caroline West: I guess it gets back to that sense of having a strengths-based approach, where you really draw upon somebody's strengths within their own individual story and within their community, and put a framework around their experience that makes sense and gives them hope.

Rebecca Davison: I think it can be very empowering for young people to hear that, particularly from their GP, where there's that power imbalance to hear from your GP that you're strong and there are great things about you. It can be empowering and really motivating towards their journey to recovery and wellness.

Caroline West: Fantastic. Well that's a great note to end on and I've really enjoyed our yarn today. It's been fantastic to get a sense of your experience and your stories, Rebecca, Jamie and Sarah. It's been really special having you today on the NPS MedicineWise podcast, so thank you very much for your time.

Rebecca Davison: Thanks, Carolyn.

Caroline West: Thank you. And if you'd like any more information on this podcast, or some of our consumer resources on young people and mental health, you can go to our website at nps.org.au. There have been no conflicts of interest declared for this podcast. My name is Dr. Caroline West. Bye for now.