Understanding and working with different worldviews to co-design cultural security in clinical mental health settings to engage with Aboriginal and Torres Strait Islander clients

Abstract

Background:

Creating the conditions for meaningful relationships is essential to understanding Aboriginal worldviews and co-designing ways of working to achieve better health outcomes. Non-Aboriginal health professionals struggle to recognise the importance of social relationships to Aboriginal peoples and tensions emerge due to these different worldviews informed by different ontologies and epistemologies. This is more so in clinical settings where training and models of care are often inadequate for working with Aboriginal people. The impact of different understandings of relationships on the provision of health services to Aboriginal peoples remains under-researched. There is a critical need to reassess the way clinicians are supported by their organisations to engage with Aboriginal clients in competent and meaningfully ways.

Methods:

The paper provides key insights into an Aboriginal-led participatory action research project and the work of Aboriginal Elder co-researchers with non-Aboriginal mainstream service staff to better understand the importance of social relationships from an Aboriginal worldview. The paper critically engages literature on clinical service provision for Aboriginal peoples, along with an examination of the Australian Psychological Society Code of Conduct, to explore the tensions between professional training and the need to build relationships with Aboriginal clients.

Findings:

Through the Elders, non-Aboriginal service staff have expanded their understanding of Aboriginal culture, kinship and the importance of country to Aboriginal wellbeing. The Elders mentored staff to unpack the tensions between worldviews in clinical settings. The research resulted in a co-designed culturally safe framework for non-Aboriginal practitioners, which is building confidence, capacity and competence to work in partnership with Aboriginal peoples. The framework emphasis the need for culturally safe models of care. The Elders have supported non-Aboriginal staff to sit between the two worldviews to develop ways to work with Aboriginal clients and shift mainstream models of mental health care to improve the wellbeing of Aboriginal people.

Introduction

We’ve been adapting for over 200 years. It’s about time white fellas did some cultural adaptation and learned more about our Nyoongar [Aboriginal] culture and ways so they can work better with us (Nyoongar Elder co-researcher interview, 2015).

There are ongoing tensions in how Aboriginal ¹ and non-Aboriginal peoples in Australia understand and interpret their very different worldviews, which are reflected in different ontologies (ways of doing) and epistemologies (ways of knowing) (Rigney, 2001; Foley, 2003; Durie, 2004; Dudgeon & Fielder, 2006; Nakata, 2010). Significantly, non-Aboriginal people often struggle to understand Aboriginal worldviews and, in particular, how social relationships are shaped in societies that are kin-based (Dudgeon, Wright, Paradies, Garvey, & Walker, 2014; Dudgeon, Bray, D’Costa, & Walker, 2017). For example, relationships in kin-based societies are inclusive and reciprocal yet these characteristic Aboriginal ways of being are frequently absent in mainstream non-Aboriginal organisations, their systems and practices, where there are limited numbers of Aboriginal counsellors and little access to Aboriginal forms of healing. Combined with a general inflexibility in organisational governance structures and processes, this means that changing how non-Aboriginal professionals work with, and relate to, Aboriginal people, their families and communities is a challenging but necessary pursuit (for example, Isaacs, Pyett, Oakley-Browne, Gruis, & Waples-Crowe, 2010; Molloy, Walker, Lakeman, & Lees, 2019).

These differing worldviews and ways of working are brought into sharp focus in clinical mental health settings and are evident in the angst and confusion often present amongst non-Aboriginal psychologists and mental health practitioners who work with Aboriginal clients. Many non-Aboriginal practitioners describe tensions between their professional training and their relationships with Aboriginal clients and communities when providing psychological services and therapeutic care (e.g. Sheldon, 2010; McConnochie, Ranzijn, Hodgson, Nolan, & Samson, 2012; Dingwall, Pinkerton & Lindeman, 2013) Similarly, Aboriginal clients struggle with this misalignment in worldviews resulting in reluctance to access mainstream mental health services (Dudgeon, et al., 2017; Wright, Culbong, Crisp, Biedermann, & Lin, 2019). However, to develop new ways of working together to achieve better health and well-being outcomes, mental health clinical practice must adapt to honour Aboriginal social relationships (Sherwood, 2013; Wright, O’Connell, Jones, Walley, & Roarty, 2015).

Hopper’s ‘murky middle ground’ (Hopper, 2013) reflects the complex and messy nature of navigating inflexible systems that find professionals stretching their capacities and contending with ‘ethics, disciplinary duty and civic responsibility’ (Hopper, 2013: 203). Different worldview experiences between practitioner and client then expose the ethical dilemmas non-Aboriginal practitioners face in their work practices. In most cases, the dominance of Western cultural practices in psychological training and therapeutic models can result in culturally irrelevant and ineffective services with the potential to cause more psychological harm (Hayman, White, & Spurling, 2009; McConnochie, et al., 2012; Ranzijn, McConnochie, & Nolan, 2009; Sherwood, 2013). Communication and developing the conditions for meaningful relationships are essential in deepening non-Aboriginal peoples’ understanding of Aboriginal worldviews in clinical contexts, yet self-disclosure and personal relationships are not encouraged in Western therapeutic practice (Dingwall et al., 2013; McConnochie et al., 2012). It is therefore necessary and important to reappraise and reprioritise mental health practices so that these reflect a better understanding of an Aboriginal worldview and the value in social relationships (Wright, Culbong, Jones, O’Connell, & Ford, 2013, Wright, Culbong, O’Connell, Jones, & Ford, 2013, Wright, et al., 2015, Wright, Lin, & O’Connell, 2016). It is, however, imperative that Aboriginal peoples lead reform efforts, whereby non-Aboriginal health professional educators, policymakers and practitioners alike consciously ‘tolerate the discomfort’ and upheaval this may cause, and be willing ‘to engage authentically’ (Castell, et al., 2018: 270).

Importantly, the impact of different worldviews on mental health clinical practice remains under-researched. In this paper, we offer insight into the challenges experienced by Aboriginal people and mental health and drug and alcohol service staff as they partner to enable the creation of services that are inclusive, safe and sustainable. Specifically, the paper draws on what was learnt from a community-driven, participatory action research project that brought together Nyoongar ² Elders, from the Perth metropolitan area in Western Australia, with local non-Aboriginal service executives and practitioners to contest the histories, values and mechanisms that present barriers to culturally secure service experiences (Wright, et al., 2015). We highlight their co-production or ‘working together’ efforts in response to the question: ‘how can the Australian Psychological Society engage their membership in conversations that challenge their purpose and practices that impact the cultural safety of Aboriginal families?’ Additionally, we weave in the current literature on mental health practitioners’ clinical practice experiences working in Aboriginal mental health (e.g. McConnochie et al., 2012; Dingwall et al., 2013), and the requirements laid out in the Australian Psychological Society (APS) Code of Ethics (APS, 2010), to illustrate current barriers and enablers to culturally secure practice for Aboriginal clients.

The Looking Forward Project was undertaken on Wadjuk Nyoongar boodja, the lands of the Wadjuk people of the Nyoongar Nation, and we pay our respects to their Elders past, present and emerging, and are deeply grateful for their wisdom and guidance in our work. We acknowledge our shared voice in this paper, as Aboriginal and non-Aboriginal research colleagues. We work within academic and service provision spaces, as well as those spaces where we are invited by the Nyoongar community to work alongside them and, in particular, under the guidance of the Elders. These spaces hold our identities as multiple, contested and dynamic. Michael is a Nyoongar man and lead researcher on the Project. Jonathan is a Nyoongar man with family ties to Wardandi and Yamatji country on his mother’s side, and Bristol, England, on his fathers. Margaret is a nyidiyang, a non-Aboriginal person of Anglo-Celtic decent, born, raised and working on Nyoongar boodja. Ashleigh is a nyidiyang born in South Africa and lives and works on Wadjuk Nyoongar boodja. Helen too is a nyidiyang born overseas, grew up and lives and works on Wadjuk Nyoongar boodja.

Background: the looking forward project

The Looking Forward Project engaged a group of twenty local Nyoongar Elders to work directly with organisations who delivered mental health and drug and alcohol services in the metropolitan area where the Elders and their families lived. Through a series of community forums conducted in 2011 and 2012, it was evident that the lack of trust and engagement between the community and service providers was leading to ineffective and culturally unsafe services (Wright, et al., 2015). During the co-design phase of the Project, Elders and participating services, non-Aboriginal executive staff and practitioners, created a framework for meaningful engagement shaped by the conditions necessary to ensure effective working relationships between Aboriginal clients and non-Aboriginal practitioners. Stakeholders agreed to the following terms of engagement: (i) be open to working boordiya to boordiya (‘boss’ to ‘boss’), (ii) be willing to better understand the impact of white privilege, (iii) be humble enough to be guided by Elders and (iv) be open to new ways of working (Wright, Lin, & O’Connell, 2016).

After working together, there has been an increased awareness of Nyoongar culture by services through local events and cultural activities, increased trust between services and the community and enhanced respect through the ongoing engagement of Nyoongar Elders across the services (as cultural consultants and advisors) (Wright, et al., 2015). In addition, there is a renewed commitment from services to continue this work through an evaluation project to build a greater evidence base to promote reform across the mental health and drug and alcohol sectors. This evaluation project is the Looking Forward Moving Forward Project and is funded by the National Health and Medical Research Council, Australia (Western Australian Aboriginal Health Ethics Committee, HRE772, Curtin University, HRE2017-0446).

By establishing trusting and respectful relationships that honour the past and privilege a Nyoongar worldview, service staff found themselves in a different position to reframe the way they respond to the needs of Aboriginal clients and their families living with mental illness. Through these relationships service staff critically reflect on their worldviews and better understand the impact of their professional practice, shaped by their worldviews, on the client experience. The Project is one example of research that captures and responds to the viewpoints of Aboriginal clients and their interactions with services in an effort to shift mainstream models of mental health care to improve the cultural security of services providing care to Aboriginal peoples. It uses participatory action research informed by Indigenous cultural protocols to bring service staff together with local Elders. It achieves a balance between scientific research and cultural protocols to ensure the research methods are culturally secure and respond to the priorities expressed by the Nyoongar community.

Mason Durie, a senior Maori researcher in Indigenous health, provided a blueprint for how science and Indigenous knowledge can co-exist (Durie, 2004). His work has shown that, however, unlikely it might appear, there are many commonalities between Aboriginal and non-Aboriginal worldviews, for example, an adherence to the principles of respect and dignity (e.g. Durie & Kingi, 1997:29), the value of good health and well-being, and the innate need for both personal and wider social relationships (e.g. Durie & Kingi, 1997:15, 60). These commonalities can complement and enhance service provision and research practices. He claims that where differences exist they do so because of intractable ideological positions. He cites numerous collaborations between mainstream health researchers and Maori people where the Maori worldview is given serious consideration, and in those instances has produced results that have enhanced health and well-being outcomes (Durie, 1995; Durie & Kingi, 1997).

Overarching project methodology

‘When other organisations and things start, they start implementing this way of working and then you’ll see it affecting all the community’ (Elder co-researcher, 2018).

Participatory action research emphasises mutual respect and co-learning between stakeholders, facilitates individual and community capacity building, drives systems change and promotes a balance between research and action (Wallerstein & Duran, 2006; Wallerstein & Duran, 2010). To this end, it was deemed fitting to utilise a co-design approach to engage stakeholders to direct the research itself. Co-production, or co-design, is an oft-used term that highlights direct input from health care consumers to ensure services remain relevant and responsive to their needs and priorities at any given time (Boyle & Harris, 2009; The Australian Centre for Social Innovation, 2013; Lwembe, Green, Chigwende, Ojwang, & Dennis, 2017). It is an increasingly popular mode of working and one which aligns with participatory research methods and community-based initiatives to empower participants to engage in the design and development of services and programs that impact them directly (Slay & Stephens, 2013).

The key principles that underpin co-production in research include shifting power and the development of reciprocal relationships. Both of these principles need to occur between professionals and people and their families using services if sustainable change is to be realised (Slay & Stephens, 2013). In an Aboriginal context, this means ensuring that trust, reciprocity and flexibility are developed (The Australian Centre for Social Innovation, 2013; Wright, et al., 2015). Unless there is trust, any initiative undertaken with Aboriginal people will fail. In regard to reciprocity, shared decision making and flexibility are essential for developing an enduring foundation of trust and people’s adaptability to change research practice. Working with and in communities who have been disenfranchised and marginalised also requires an understanding that there is a responsibility to use the research findings as part of a healing process, and to challenge and dismantle structures that have oppressed and created power imbalances (Chino & DeBruyn, 2006; Wright, 2011; Dudgeon, et al., 2017).

In support of our participatory approach and to retain the guiding voices of Elders and their community, quotes from Elder co-researchers and mental health services staff are used throughout this paper. These were captured via semi-structured interviews during multiple data collection phases spanning the two aforementioned distinct, sequential research projects from 2014 through to 2019 (Wright, et al., 2015, Wright, Lin & O’Connell, 2016).

Working with different worldviews

Personal challenges: working with self-disclosure

Self-disclosure can be difficult for non-Aboriginal practitioners. Given the complexity and importance placed on privacy and confidentiality, the practice of non-disclosure is, understandably, considered to be best practice. The argument for non-disclosure is that personal boundaries should never be violated in the therapeutic space, and self-disclosure could compromise the objectivity of the practitioner. Indeed the APS Code of Ethics under General Principle B: Propriety states that psychologists ‘are aware of, and take steps to establish and maintain proper professional boundaries with clients’ (APS, 2010:18). The notion of ‘proper boundaries’ defined by the practitioner (and their discipline) alone is fraught and likely to lead to the very issues we seek to highlight in the provision of culturally secure models of care. Our study and the findings from other studies have shown that appropriate self-disclosure can greatly enhance the capacity of a non-Aboriginal practitioner to build trust with Aboriginal clients. For example, as one non-Aboriginal practitioner reflects:

Self-disclosure is more important to Indigenous people. That one seemed challenging for me, because I was trained never, you just do not talk about yourself (McConnochie, et al., 2012: 207).

Similarly, in The Looking Forward Project, at an early meeting with the Elders and senior managers from the participating organisations, one Elder challenged the non-Aboriginal managers saying:

You fellas [service providers] know so much about us, but we know nothing about you (Wright, et al., 2015: 59).

In later meetings, the Elders acknowledged the openness of service staff to learning as they developed their relationships with them:

‘There’s an acknowledgement and an openness about what they don’t know, all the time, and equally an acceptance and an acknowledgement about their openness to learning’ (Elder co-researcher, 2015).

The Elders reiterated that trust needs to be established and for it to be sustained Aboriginal people do need to engage on a personal level with mental health practitioners. Non-Aboriginal practitioners need to find ways that will allow them to be more open to self-disclosure without compromising their professional standards. This can be achieved through first defining what it means to be in relationship with others. Engaging with Elders enables non-Aboriginal practitioners to heighten their awareness of their role and critically reflect on power (im)balances. It allows practitioners and other service staff to pause, providing space and time to contest entrenched professional standard values and ‘objective’ practice in ways that can be unsettling. However, non-Aboriginal practitioners must seek to engage in a respectful, personable manner that acknowledges the different worldviews of their clients and offers some relational opportunities to understand these differences. The Elders prepare them for this, for example:

‘These fellas, they come from overseas, so we’re along the same lines, but they’re sharing their stories with us and we’re sharing our stories with them, so we’re getting a reciprocal understanding’ (Elder co-researcher interview, 2015).

‘One of the things that I’ve personally been really appreciative about is that they’ve been prepared to listen and understand about the importance of wirrin (‘spirit’) with our mob and the fact that because of the issues, particularly that we’ve been able to talk about at those meetings with them, they are starting to understand that we have - our people have a really - an equal level of importance in terms of looking across the community, different cultures and stuff like that’ (Elder co-researcher interview, 2015).

Dingwall and colleagues interviewed psychologists about their work practices and noted how those who made personal connections enabled Aboriginal clients to feel more comfortable in the therapeutic space:

Oh yeah, there’s that level of personal disclosure, I’ll talk about my family background and what my family background and what my connections are, I’ll talk about football, I’ll talk about fishing or whatever is going to start a connection between us (Dingwall et al., 2013: 8).

The result of months spent meeting with local Elders and engaging in a personal ‘storying’ process, non-Aboriginal practitioners in the Project described developing a greater level of confidence to work with Aboriginal clients through disclosing personal information (Soong, et al., 2015). The ‘storying’ process emerged through the research as an essential component to establishing relationships to navigate different worldviews and also formed part of a latter project involving Aboriginal and Torres Strait Islander young people:

Engagement in shared story experiences lays the foundation for locating and reconciling points of difference and confirmation of mutual benefits and concerns that are often not discussed in cross-cultural settings (Wright, et al., 2019: 4).

Through the storying experience and hearing the lived experiences of Aboriginal people accessing services, non-Aboriginal practitioners explored the alignment between their personal ethical stance and professional code of conduct. The process of engaging enabled them to integrate differing worldviews and begin their personal change journeys. Storying established a firm foundation on which to enhance their competence in working with Aboriginal people and resulted in Aboriginal clients more readily and consistently engaging with the service. By strictly abiding by the rules for disclosure set out in the APS Code of Ethics (2010), practitioners severely limit their opportunities to explore the possibilities of genuine trust-building and connection with Aboriginal clients.

Working with different communication styles

Managing different communication styles also emerged as a key challenge for non-Aboriginal practitioners who are often challenged by unfamiliar ways of communicating. A quote from a practitioner about different communication styles is revealing:

She growled me out. I did know about growling and so I knew to just kind of stand there and take it and she gave me a bit of a serve, and at the end of it I said. ‘Okay, thank you for that and can we have a chat now? Okay I know my place now and now that I do, can we start from that place?’ And I think that that raised a great deal of respect (McConnochie, et al., 2012: 208).

‘Growling’ or ‘being growled’ (Westerman, 2008) is an experience that often occurs between non-Aboriginal practitioners and Aboriginal people. In a Nyoongar context ‘growling’ or ‘being growled’ is referred to as ‘being jarred’, and it means ‘being put in your place’. Being jarred or being growled can be a very disconcerting experience. Developing an understanding of these messages through very different communication styles is both a necessary and important skill. Conceptions of guilt and the fear of making further mistakes can reinforce feelings of fixedness. Non-Aboriginal practitioners must be able to critically reflect and stay present, show humility and be open to learning. It is also at this point that practitioners must develop the capacity to recognise and consciously steer from ‘known’, typical, or ‘usual’ trajectories of response towards those that may better meet the client’s needs. This form of response, particularly when at the threshold of potential rupture, is more likely to establish trust with Aboriginal people than an adherence to the familiar position of expert.

The difficulties experienced by the service providers in the Looking Forward Project were similar to the discomfort generated from ‘being growled’ at, as this quote from a service executive manager (drawn from the Project report) attests:

I’ll be honest; there have been times when it’s been incredibly uncomfortable just because I’ve never sat around the table with Aboriginal Elders before. My sense is that - or my feeling is that if you put me in a room leading a meeting amongst service providers or with other staff, I know the unwritten ground rules and I know how things work and how things operate but if you put me in a group… any meeting with Aboriginal Elders, I don’t know what the unwritten ground rules are and I’m learning very slowly. They’ve been very welcoming and very approachable but just from myself, I just think having a complete lack of confidence in myself to know what is appropriate (Wright, et al., 2015: 61).

In their interactions with Aboriginal people, non-Aboriginal practitioners do need to develop the confidence, humility and internal fortitude required for working with Aboriginal people. One service manager realises the value of yarning to enhance learning:

…so through my various journeys including the [Project], valuing yarning, listening to Aboriginal staff but there was a lot of other things from my general professional experience. Often those first good conversations actually have the seeds of everything you want just about anyway and everything after that is refinement… (Service Manager interview, 2018).

Cross-cultural communication can be difficult and challenging, but also very rewarding and oftentimes seen as reciprocal learning together as one Elder in the Looking Forward Project reflected: ‘…our work becomes more effective. That is the good thing about it. This changes us for the good. The little things we pick up and learn from each other helps us’ (Wright, et al., 2015: 60). Communication and staying connected requires sustained effort, patience and confidence. It requires the belief that working towards mutually respectful relationships will allow open, meaningful communication to occur. Indeed, the APS Code of Ethics promotes that ‘psychologists communicate honestly in the context of their psychological work’ (APS, 2010: 26, emphasis added). Staying connected and accepting the challenges of cross-cultural communication is one way of ensuring this occurs.

Working in the murky middle ground: integrating new learning

Being flexible and adaptable with work practices is necessary for working with Aboriginal people. Indeed, the Elders participating in the Project have made it clear that work practices need to be adaptable if they are to be appropriate for Aboriginal people:

[Needs to be] more people on the ground. Not 9 – 5. Not sitting in their seats. What happens is happening in the evenings. When the businesses shut down there’s no-one out there. Health is 24/7 (Wright, et al., 2015: 61).

The importance of being adaptable in their work practices is highlighted by the following quotes from non-Aboriginal practitioners describing the strategies they used for building trust:

Most people would go twice; we go ten times or twenty times or whatever. And you just keep going until you sort of feel that you know them more and they trust you more and they’ll talk to you more and they’ll give you more information (Dingwall, et al., 2013: 8).

What I did is I delivered a service out to them. I took the service to them and I’d sit down on the creek bed, have the billy tea pot boiling and we’d talk about, you know, domestic violence, but we’d talk about it in an appropriate way (McConnochie et al., 2012: 208).

As a result of engaging with local Elders, one Project partner revealed how staff in a regional site have taken to ‘roaming’, effectively turning their service inside-out to be more visible to the community and walking amongst them:

‘…the message loud and clear that if we were going to be successful in setting up an office in a town with a large proportion of Aboriginal people and outlying towns with large amounts of Aboriginal people, we had to do it differently and so we said, “fine let’s do it differently. Let’s go with it, let’s go with the process” and going with the process of roaming, which was a very difficult concept and vouching. So vouching was a lot easier to understand, roaming was really about fluidity and not immediately having a structure and… enabling the staff time to connect and to build relationships without necessarily saying, “well have you seen your five clients today?” because it wasn’t about that, it was about building relationships on the ground’ (Service executive interview, 2018).

This appears to be incompatible with the APS Code of Ethics Ethical Standards on Competence, where practitioners are instructed to provide ‘psychological services within the boundaries of their professional competence… (including)…. within the limits of their education, training, supervised experience and appropriate professional experience… (and)… based on the established knowledge of the discipline and profession of psychology’ (APS, 2010: 18). Systemic structures reflect dominant Western worldview. In this paper’s context, Western structures are powerfully influential in two ways, both constricting the capacity and openness of non-Aboriginal practitioners to accommodate different lived experiences, but perhaps, more importantly, reinforcing to practitioners that the bounds of existing structures contain ‘all there is’ to the discipline of psychology and its professional practice. In contrast, we argue that uncertainty and unfamiliarity – across individual and systemic levels - must occur for non-Aboriginal practitioners to provide ‘culturally appropriate services’ that genuinely respond to the expectations of the community they serve (APS, 2010: 11). Once more, worldviews are contested at the interface between policy guidelines and lived experience. Non-Aboriginal practitioners who have built authentic and genuine relationships with Elders during the course of the Looking Forward and Looking Forward Moving Forward Projects have particularly felt this ethical dilemma. On the one hand, their professional practice standards are a marker of their integrity and, on the other hand, their relationships with Elders are highly valued. For example, one mental health service team reflects on this clash of values and how any actions taken have the potential to either disrupt their professional standards or alternatively diminish their newly formed relationships with Elders, in a recent publication: ‘As clinicians in the mental health system, we work within a rigid framework focused on key objectives and outcomes. Our involvement in [the Project] has lacked these distinct features’ (Soong, et al., 2015: 39). Clearly, there is growing recognition by non-Aboriginal practitioners that relationships are at the very centre of Aboriginal worldviews; to support, guide, nourish and heal all involved. We suggest that this relational development is an outcome in and of itself, though not necessarily accommodated in formal standards of practice, something this mental health service team in particular found difficult to reconcile.

On Country and local community activities and events have served as a practical means to deepening relationships between communities and non-Aboriginal practitioners:

‘…it’s the combination of all the different activities that we are doing, so the NAIDOC Week, the Sorry Day, the Reconciliation Walk, we are seeing more of an understanding and empathy, coupled with the training, so people are getting a better understanding, both formally and experientially around the importance of First Peoples and I think more respect for First Peoples.’ (Service Manager interview, 2018).

The practitioner’s comments below are reflective of the need to understand why adaptability is necessary to work more effectively with Aboriginal people, as one practitioner explains:

…the model that I like to use is one that requires me to really slow down and not ask too many questions…It actually brings up a lot of anxiety for me as a clinician needing to work to a schedule and get answers from a client. But that’s my anxiety; it’s not the client’s (McConnochie et al., 2012: 207, emphasis added).

This type of working practice (i.e. to slow down and not ask too many questions) has been a recurring theme between the Elders and non-Aboriginal practitioners in the Project. The Elders would regularly remind staff to slow down and listen; debakarn, debakarn (‘steady, steady’), thereby modelling inclusiveness and patience, as well as their ability to hold the group. The Elders were indeed skilful guides within the spaces they shared with staff through their use of humour and wisdom:

To come together and to hear the ideas that challenge systems to work with Aboriginal people has been really, really interesting, because it’s the systems that need to change in order to make a difference for our people, and this process will take a while. It’s not going to happen overnight. They have to go through this process - they’ve got to go through these processes to get to the place where they can come back and say well, your worldview is the only view that can help your own people and they’re prepared to step into our worldview (Wright, et al., 2015: 39).

Service providers have learnt that to fully integrate any learning requires letting go of many preconceived ideas, and allowing the process to follow its own course, trusting that the relationships they have come to develop with the Elders will serve as a protective factor to the level of uncomfortability and tolerance of uncertainty they experience (Bergström, Seikkula, Alakare, et al., 2018: 196; Castell, et al., 2018: 270). This can be very confronting but also liberating as the following comments by service executives, captured in the Looking Forward Project report, illustrate:

‘As is often the way with non-Aboriginal people we wanted to ‘fix’ everything quickly and looked for the most streamlined and efficient means of getting the outcomes we were looking for. There were many instances where …the Elders had to remind us to slow down and look at the process of change, the relationships we needed to build with the Elders and their community and to let things evolve naturally and organically. In this Project it isn’t possible nor wise to put strict timelines or time pressures on ourselves, instead we need to trust in the process, be patient and be held by the Elders and let the process evolve naturally. This has certainly shown to be the best in the long run and has delivered results far beyond what we ever thought imaginable’ (Wright, et al.,2015: 47).

‘…we have had to stay at the table and have not given up when challenged, or when other apparently more immediate priorities have appeared on our desks. Giving time to the conversation, time to reflect on what is said (and not said) and learning to value what giving that time can achieve, are key learnings…’ (Wright, et al., 2015: 73).

This remained the case as service executives continued to deepen their relationships with the Elders over time:

‘…there is an energy, but there is also I think a dawning reality that we don’t have a right to be in this space unless we’re doing it differently’ (Executive staff member interview, 2017).

The Elders involved in the Projects have been the teachers and guides for service providers. Integrating the learning is critical and essential for effective engagement with Aboriginal clients and for change to occur, but takes time. As a result, service providers have a much deeper understanding of what constitutes a Nyoongar worldview, which has enabled them to work more skillfully and effectively with Nyoongar people. The next step for non-Aboriginal practitioners and their organisations is to sustain their effort.

Discussion: navigating worldviews as personal change journeys

As argued, the clinical interface that exists between non-Aboriginal practitioners and Aboriginal people brings together differing worldviews and as a result is often a source of discomfort, angst and confusion for both practitioners and clients (Dudgeon & Fielder, 2006; Dingwall & Cairney, 2009; McConnochie et al., 2012; Wright, et al., 2015; Dudgeon, et al., 2017). Findings from the Project revealed the challenge for non-Aboriginal service providers is to see change as a personal journey, as illustrated by this comment from one of the Elder co-researchers: ‘If you’re not going on the journey, then you are not learning. We have to walk this journey together’ (Wright, et al., 2015: 59).

McCoy (2009) suggests that when the opportunity arises to engage with Aboriginal people, non-Aboriginal practitioners must seek personal discovery and transformation. If not, then practitioners must reflect on whether they are suited to such work. The notion of a ‘personal journey of change’ offers practitioners the opportunity to pause and ask what it is they are entering into when they engage with Aboriginal people. It is no longer simply a clinical setting (Mattingly, 2018). Non-Aboriginal practitioners often experience feelings of uncertainty and discomfort when working in cross-cultural environments (McConnochie, et al., 2012; Dingwall, et al., 2013; Wright, et al.,2015; Castell, Bullen, Garvey, & Jones, 2018). These feelings may result in reactive practices that do not allow sufficient space to think and consider before acting. Thus, professional preparation can be compromised just as the client’s therapeutic experience is likely to also be compromised. Cultural differences can elicit experiences of not knowing and feelings of being uncomfortable, exposing the differences between ethical practices and lived experience. On these occasions being able to critically reflect on one’s practice as a personal journey of change offers a point at which to pause and reflect and then re-engage differently. It also provides an opportunity to clarify one’s own position before entering a practitioner–client relationship. In working with Aboriginal people, an inability or unwillingness to ‘not know’, feel uncertain and experience the unknown can affect the authenticity necessary for meaningful engagement (Castell, et al., 2018). Certainly, the ability to critically reflect on one’s therapeutic relationships is an essential aspect of good psychological practice (APS, 2010). However, a tension that arises here is that practitioners are also encouraged to work within the ‘limits of their education, training, supervised experience and appropriate professional experience’ (APS, 2010: 18). To this end, practitioners are inadvertently left to contend with this dichotomy with no apparent guidance.

Engaging in a reflective practice that allows non-Aboriginal practitioners to better understand their personal journey of change and to ask themselves important questions about their preparedness to be in the contested spaces they share with Aboriginal clients. For example, is the space an appropriate setting, not only for clients but also for practitioners themselves? Is it a space in which clients can meaningfully engage in therapy? Do non-Aboriginal practitioners have sufficient understanding of the context in which they practice in order to inform their decisions when assessing Aboriginal clients (e.g. Dingwall, et al., 2013)? Aboriginal clients also need the opportunity to undertake a ‘personal journey of change,’ for at present they regularly have little or no say on how or what should be included in the therapeutic space, such as how the space should be arranged, where the sessions should take place and critically what it is that actually occurs in the therapeutic process. To share in the concept of personal journeys of change offers a unique opportunity for both practitioners and clients to pause and explore both their inner and outer realities prior to entering their shared therapeutic experience. We suggest that trying to change behaviour through an understanding of what is different between cultures and then trying to fit therapeutic models to work with individuals is often neither relevant nor appropriate. Instead, identifying the strengths in the respective cultures and the commonalities that exist between cultures and working with these to devise and at times, co-design appropriate therapeutic models (Boyle & Harris, 2009; The Australian Centre for Social Innovation, 2013; Wright, et al., 2015). Service managers contend with this alteration as they begin their engagements with the Elders. Time, for example, is a key ingredient that highlights different worldview experiences and philosophies:

‘A key ingredient is time and I look at any other culture that I’ve managed to get to what I would call a stage of confidence, capacity and competence in terms of understanding and being able to have that respect and shared understanding across that cultural boundary and it takes time, certainly more than a few yarning sessions with Elders. So to me the big take-home about this or how I’m looking at this is it’s going to take time and it’s going to take that investment of effort and energy into those relationships in a meaningful way, so it’s kind of a big thing.’ (Service Manager interview, 2017).

In response, the Elders express a different understanding of time that reflects the importance of relating to (and with) others:

[Time] is not important to us. Time is different. We do not worry about time, we worry about getting the job done. And it does not matter if it takes five minutes or takes an hour, or takes a week. As long as we get the job done we are satisfied (Elder co-researcher interview, 2015).

Culturally secure clinical practice requires much more than simply changing behaviour on the part of the non-Aboriginal practitioner. There is an opportunity to take up a more considered co-design approach that draws on the experiences and realities of the practitioner and the client, together. To do this well requires a re-valuing of individual investments in relationships. Non-Aboriginal practitioners are then faced with the dilemma of contesting their own worldview understandings of professional practices such as managing self-disclosure and different communication styles. These aspects lie at the heart of the APS Code of Ethics General Principle A: Respect for the rights and dignity of people and peoples (APS, 2010) and indeed shake the very foundations of clinical practice. We would argue that the capacity of practitioners to develop a shared understanding and accept the uncertainty that awaits them in therapeutic spaces with Aboriginal clients is congruent with having ‘a high regard for the diversity and uniqueness of people and their right to linguistically and culturally appropriate services’ (APS, 2010:11).

Conclusion: Committing to work together

To take agency seriously is to recognise and embrace the challenge of integrating the key learning from the practitioners’ and Elders’ experiences described here. The common themes across the literature and in the Looking Forward and Looking Forward Moving Forward Projects remind us of the urgent need for change in the provision of clinical services for Aboriginal peoples and, we hope, provide some direction on how change may occur at a systemic level, beginning with relationships.

The Projects have demonstrated that in order to engage Elders as the drivers for change in mental health service delivery, non-Aboriginal practitioners must anticipate and be willing to contend with unsettling experiences of worldviews other than their own. Such experiences have the potential to inform new ways of working and in turn expose the very systems by which discrimination and cultural bias are promulgated. The Elders’ cultural authority provides legitimacy to the work, and their ongoing interactions with the service providers communicates a powerful message to the community that the organisations can be trusted. The evaluation phase of the Looking Forward Moving Forward Project is underway and aims to develop an evidence base to demonstrate that the ‘hands on’ involvement of the Elders with each organisation has increased the level of acceptance of those organisations by the Aboriginal community. The Elders are the portal to the community, and their work with individual services provides the foundation for building bridges into the community. This level of community acceptance is only likely if paralleled by the level of acceptance and respectful acknowledgement of Nyoongar culture by mainstream service providers as key to the outcomes of the Project. These outcomes are made possible by firstly, the close working relationships that have developed between senior management, practitioners and the Elders, resulting in positive attitude and behaviour change by staff within each of the participating organisations. Secondly, the engagement of Elders has been an empowering experience that initiated transformational personal change that has led to organisational change. Working with senior management highlighted the Elders’ integral leadership role as senior custodians of cultural law and kinship. Thus, non-Aboriginal practitioners and service leaders have come to recognise that Aboriginal Elders are central to the health and well-being of Aboriginal people and the continuation of culture. Taking up the opportunity to work in a leadership capacity alongside service executives and staff has also enhanced Elders’ own health and well-being (Durie, 2004: 1142). So too, ethical guidelines based on Indigenous knowledge provide clear protocols on which to base new ways of working (Pyett, 2002; Durie, 2004; Chino & DeBruyn, 2006), as one Elder stated at the outset of the Project:

‘…it’s like having a different kind of leadership within these organisations that demonstrates something - it’s a feeling with the heart; leading with the heart, not just with the head, not always just with the head. With their hearts. That’s where we want that leadership to get to in the end’ (Nyoongar Elder co-researcher interview, 2012).

It is our intention that this article disrupt and challenge the current views on therapeutic practices in the provision of clinical mental health services to Aboriginal people. Serious questions remain about both the appropriateness and effectiveness of practitioners and the existing models of care for Aboriginal people. Practitioners have a duty of care to ensure they do no harm, so they must ‘exercise their power appropriately and honour this position of trust’ (APS, 2010: 26, see also Wallerstein, 1999). We have attempted to answer the question: ‘how can the APS engage their membership in conversations that challenge their purpose and practices that impact the cultural safety of Aboriginal families?’ We have outlined the elements we believe are essential for non-Aboriginal practitioners to maintain their own integrity and that of their clients in contested therapeutic spaces and, in particular, how to challenge the unequal balance of power in clinical settings. These elements include the need for practitioners to consider the personal challenges they face and explore ways they can work with a greater degree of self-disclosure and be mindful that different communication styles are required to develop a safe and inclusive therapeutic space in which to work with Aboriginal clients. Lastly, non-Aboriginal practitioners must be flexible and adaptable in their work practices, which is a necessary skill for working with Aboriginal people. In the spirit of co-design evident in the outcomes achieved by the Projects, a review of the APS Code of Ethics is recommended, as it falls markedly short of addressing the dedicated supports required for practitioners to offer culturally safe care for Aboriginal people.

Working with marginalised and disenfranchised populations such as Aboriginal people is challenging and can at times be quite perplexing. Contested spaces are fraught with ambiguity and are opaque, messy and uncomfortable. Yet practice calls for deep critical reflection, openness and a willingness to learn as ‘[e]thics, disciplinary duty and civic responsibility are all at issue’ (Hopper, 2013: 203). Failure to do so would be catastrophic. We believe the challenge for practitioners is one of relevance; that is, their relevance to the community and the perception by the community of their role in providing culturally safe mental health care.