Future Directions In Aboriginal And Torres Strait Islander Social And Emotional

Wellbeing, Mental Health And Related Areas Policy

Prepared by Professor Pat Dudgeon, Professor Tom Calma AO and Christopher Holland

July 2015

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Summary - Future directions in Aboriginal And Torres Strait Islander social and emotional wellbeing, mental health and related areas of policy

The mental health gap

There is a significant and growing gap between mental health and related outcomes reported for Aboriginal and Torres Strait Islander peoples and non-Indigenous people in Australia:

• In 2010-11, there were over 13,000 hospital separations for mental health conditions for Aboriginal and Torres Strait Islander peoples. This was 2.1 times the rate for non-Indigenous Australians and accounted for 7.5 per cent of all hospital separations for Aboriginal and Torres Strait Islander peoples (AIHW, 2012; AIHW, 2012a).

• Aboriginal and Torres Strait Islander deaths by suicide occur at approximately double the rate of other Australians: at approximately 100 deaths per year during 2001-2010 (ABS, 2012). The ABS reported 117 Aboriginal and Torres Strait Islander deaths by suicide in 2011-12 (ABS, 2014).

• Hospitalisation for intentional self-harm among Aboriginal and Torres Strait Islander peoples has increased by 48 percent since 2004-2005 (SCRGSP, 2014).

Closing the mental health gap can be expected to make a critical contribution to achieving the COAG ‘Closing the Gap’ Target to close the gap in life expectancy by 2030. Mental health and related conditions have been estimated to account for as much as 22% of the health gap measured in Disability Life Adjusted Years (twelve percent to mental health conditions, four percent to suicide, and six percent to alcohol and substance abuse) (Vos et al, 2007:2).

High rates of substance abuse disorders are reported in the Aboriginal and Torres Strait Islander prison population. A 2008 Queensland study reported substance abuse disorders were the most common mental health problem detected – in 66% of the men and 69% of the women assessed, often co-morbid with other mental health conditions (Heffernan et al, 2012).

Mental health conditions and substance abuse disorders impact on many areas of Aboriginal and Torres Strait Islander life, including the Australian Government’s indigenous Affairs priority areas: school attendance, employment and community safety. Addressing mental health conditions and related areas will support better outcomes in these priority areas.

Recognising improving mental health as an Indigenous Affairs priority

Aboriginal and Torres Strait Islander mental health should be made a priority in both the Indigenous Advancement Strategy and the COAG Closing the Gap Framework. The latter could include a target to close the mental health gap by 2030, reflecting the connection between physical and mental health and the need to address both if the COAG Closing the Gap 2030 life expectancy equality target is to be achieved.

The target of closing the mental health gap by 2030, if adopted, should be measured using the indicators developed in partnership with Aboriginal and Torres Strait Islander peoples and their mental health leaders and experts.

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Developing a dedicated Aboriginal and Torres Strait Islander mental health

A dedicated Aboriginal and Torres Strait Islander mental health plan is needed:

• to help close the mental health gap as an important goal in its own right; and

• to contribute to the broader Indigenous Affairs priorities of the Australian Government.

This plan should:

be based on the implementation of the renewed National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing currently in development;

be developed to complement the National Aboriginal and Torres Strait Health Plan Implementation Plan being released in July 2015; and

be coordinated with the implementation of the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy (2013), and the National Aboriginal and Torres Strait Islander Peoples’ Drug Strategy 2014-2019 as well as mainstream mental health policy.

A unique window of opportunity

Currently there is a unique window of opportunity for the development of such a plan. The table below lists five strategic responses within the Aboriginal and Torres Strait Islander mental health area, or that are associated with mental health in a significant way. Against each is an indication of the stage of development and implementation at time of writing.

Strategic response StatusThe renewal of the National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing.

Expected to be completed in 2015

National Aboriginal and Torres Strait Islander Suicide Prevention Strategy

Completed in 2013 but not yet implemented.

The Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project

To report in 2015 - the implementation of the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy is to be informed by the findings of the project.

National Aboriginal and Torres Strait Islander Peoples’ Drug Strategy

Expected to be completed in 2015

General population mental health planning including the National Mental Health Plan (2009 – 14) that includes planning for mainstream mental health services that Aboriginal and Torres Strait Islander peoples use.

To be renewed probably following the Australian Government’s response to the National Mental Health Commission’s National Review of Mental Health Services and Programmes expected in early 2015.

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All five strategic documents or projects are either in a late-development or pending implementation stage. Because of this, the Australian Government now enjoy a unique window of opportunity to coordinate their further development and/or implementation in an efficient and effective way.

Practically, for example, this could help support the development of (to whatever degree is appropriate) integrated mental health and social and emotional wellbeing, and suicide prevention and substance abuse disorder services, or promotion or prevention programs, that work across these areas simultaneously - for example through the integrated Mental Health and Social and Emotional Wellbeing Teams proposed by the National Mental Health Commission’s National Review of Mental Health Services and Programmes for the Aboriginal Community Controlled Health Services.

The key consideration is that just as the lived experience of Aboriginal and Torres Strait Islander people does not ‘silo’ these issues, neither should our strategic responses.

The above should be achieved through an overarching dedicated mental health plan with a defined implementation component based on the renewed National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing. With this as a guide, the strategic responses to suicide and alcohol and other drug use could be coordinated into an overarching and connected response to all these issues. Further, the ‘mainstream’ mental health system could be optimally harnessed to the same end.

In this way the risk of scattered and diffused strategic responses to mental health and related areas could be turned into an opportunity, enabling all to work together towards a common goal and to avoid duplication.

Leadership and Partnership

The implementation of the renewed Mental Health and Social and Emotional Wellbeing Framework as a dedicated mental health plan of action should occur under Aboriginal and Torres Strait Islander leadership and in partnership with their representative bodies.

Bipartisan support

It is critical that bi-partisan support is secured for the above. Improvements to Aboriginal and Torres Strait Islander mental health require generational commitments that transcend the usual lifespan of governments. As with Aboriginal and Torres Strait Islander health in general, improving mental health could be placed effectively ‘above politics’ by being included as a priority the COAG Closing the Gap Framework (which already enjoys broad bipartisan support).

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Contents

This paper starts by providing a summary of the key data and research about and existing strategic responses to Aboriginal And Torres Strait Islander social and emotional wellbeing, mental health and related areas. After considering the evidence base, and what is already in place, or in development, it sets out a vision for future directions in these areas based on the recognition of the importance of improving mental health to making gains in many areas of Indigenous Affairs including better employment, school attendance and community safety outcomes. The authors advocate for a dedicated Aboriginal and Torres Strait Islander mental health plan based on the renewed National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing currently in development. This plan will complement the National Aboriginal and Torres Strait Islander Health Plan and will help coordinate responses to suicide and alcohol and other drug use in an efficient and effective manner.

The four parts to the paper are:

Part 1 - Background: The connections between mental health and priority areas in Indigenous Affairs

• Psychological distress, mental health conditions, substance abuse disorders, and suicide ideation

• Social and emotional wellbeing, culture, resilience and better mental health• Mental health and the Indigenous Affairs priorities of the Australian Government

Part 2 - What has been achieved, or is in progress, in Aboriginal and Torres Strait Islander social and emotional wellbeing, mental health and related areas policy

• The National Aboriginal and Torres Strait Islander Health Plan 2013-2023• The National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’

Mental Health and Social and Emotional Wellbeing 2014-2019 in development• The National Aboriginal and Torres Strait Islander Suicide Prevention Strategy (2013)• The National Aboriginal and Torres Strait Islander Peoples’ Drug Strategy 2014-2019

in development• The COAG Roadmap for National Mental Health Reform 2012-22

Part 3 - What is needed?o The recommendations of the National Mental Health Commission’s National Review

of Mental Health Programmes and Services

Conclusion - A unique window of opportunity

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Part 1: Background – making the connections between mental health and other priority areas

Psychological distress, mental health conditions, substance abuse disorders, and suicidal ideation

As set out below, psychological distress and associated mental health conditions, substance abuse disorders and suicide are associated with the prolonged adversity and social determinants experienced by Aboriginal and Torres Strait Islander peoples (Sun et al, 2012).

Some of the social determinants impacting negatively on Aboriginal and Torres Strait Islander peoples’ mental health are shared with non-Indigenous people. These include poverty, poorer health and access to health services, lack of education, unemployment, lack of transport, and poor and overcrowded housing. However, they are experienced by greater numbers of Aboriginal and Torres Strait Islander people, and more intensely:

• The Productivity Commission’s 2013 study Deep and Persistent Disadvantage in Australia used the Social Exclusion Monitor populated with HILDA survey data (McLachlan et al, 2013). It reported that in 2010, about percent of Indigenous people suffered deep and persistent disadvantage compared to about percent of all Australians (ibid: 12). Deep and persistent disadvantage is broadly defined as low income and assets, deep social exclusion and little social mobility (ibid: 9).

• Adverse Childhood Experiences (ACEs) are stressful and traumatic life events for children. They can include: a death in the family; injury; household alcohol or drug problems; child abuse or neglect; living in out-of-home care; and bullying at school. In the Western Australian Aboriginal Child Health Survey 2004-05, just over one in five children were living in families where 7 or more major life stress events had occurred over the preceding 12 months. These children were five and a half times as likely to be at high risk of clinically significant emotional or behavioural difficulties than children in families where 2 or less life stress events had occurred (Zubrick et al, 2005).

• Aboriginal and Torres Strait Islander people report Stressful Life Events at 1.4 times the rate of non-Indigenous people (ABS 2013a). These can be traumatic and impact on mental health. They include: serious illness, serious accident, serious disability; death of a family member or close friend, divorce or separation, unemployment, involuntary loss of job, alcohol or drug-related problems, gambling problems, witness to violence, abuse or violent crime, and trouble with the police (ABS, 2012a).

Aboriginal and Torres Strait Islander peoples also uniquely experience additional determinants of poorer mental health. These include day-to-day and systemic racism and discrimination, disempowerment, cultural stresses, and inhibited access to country.

Compounding this, Aboriginal and Torres Strait Islander people have lower access to mental health services and professionals. In the 2012-2013 service reports for Australian Government funded medical services for Aboriginal and Torres Strait Islander peoples (including the Aboriginal Community Controlled Health Services), the most common service gaps reported by all 260 organisations in the service reports were around mental health and social and emotional wellbeing (62 percent of organisations) (Australian Government, 2014a)

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Because of the above, psychological distress is reported at very high rates among Aboriginal and Torres Strait Islander peoples, and appears to be on the rise. In the 2012-13 Australian Bureau of Statistics (ABS) Australian Aboriginal and Torres Strait Islander Health Survey, 30 per cent of respondents over 18 years of age reported having high/very high psychological distress levels in the four weeks before the survey interview. In comparison, 27 per cent of respondents reported such in the 2004-05 National Aboriginal and Torres Strait Islander Health Survey (ABS, 2013).

Trauma is often the result of violent or life-threatening stressors. Trauma is a complex phenomenon, has many symptoms and is hard to measure in a population. Post-Traumatic Stress Disorder (PTSD) is one manifestation of trauma. A 2008 study of Aboriginal and Torres Strait Islander prisoners in Queensland reported 12.1 per cent of males and 32.3 per cent of females with PTSD (Heffernan et al, 2012).

Psychological distress and trauma is a determinant of other mental health conditions including substance abuse disorders and suicidal ideation:

• In the 2008 ABS National Aboriginal and Torres Strait Islander Social Survey (NATSISS) adults with high/very high levels of psychological distress were also more likely to drink at chronic risky/high risk levels (21 percent compared with 16 percent with low/ moderate levels of psychological distress) and to have used illicit substances in the previous 12 months to the survey (27 percent compared with 18 percent) (ABS 2010).

• Suicide is a complex behaviour with many causes and is not necessarily a mental health issue in all cases. Nonetheless, psychological distress and mental health conditions are strongly associated with suicide. The Western Australian Aboriginal Child Health Survey 2004-05 reported a much larger proportion of young people at high risk of clinically significant emotional or behavioural difficulties had thought about suicide (37 per cent) or had attempted suicide (21 per cent) in the 12 months prior to the survey than young people at low risk of clinically significant emotional or behavioural difficulties (10 per cent and 3 per cent respectively) (Zubrick et al, 2005: 340).

• Some mental Illnesses are associated with psychological distress, particularly high prevalence disorders such as anxiety and depression. In short, the longer the exposure to the stressors and psychological distress, the greater the likelihood that other mental health related conditions will occur (Sun et al 2012).

However, other mental health conditions – particularly low prevalence disorders such as psychosis, schizophrenia, and bi-polar disorder – can have organic origins (DoHA, 2007).

Substance abuse disorders are often co-morbid with mental health conditions and can exacerbate their impact (ibid).

There is a significant and growing gap between mental health and related outcomes reported for Aboriginal and Torres Strait Islander peoples and non-Indigenous people in Australia:

• Aboriginal and Torres Strait Islander deaths by suicide occur at approximately double the rate of other Australians: at approximately 100 deaths per year during 2001-2010 (ABS, 2012). The ABS reported 117 Aboriginal and Torres Strait Islander deaths by suicide in 2011-

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12 (ABS, 2014).

• Hospitalisation for intentional self-harm among Aboriginal and Torres Strait Islander peoples has increased by 48 percent since 2004-2005 (SCRGSP, 2014).

• In 2010-11, there were over 13,000 hospital separations for mental health conditions for Aboriginal and Torres Strait Islander peoples. This was 2.1 times the rate for non-Indigenous Australians and accounted for 7.5 per cent of all hospital separations for Aboriginal and Torres Strait Islander peoples (AIHW, 2012; AIHW, 2012a).

Closing this ‘mental health gap’ is an important social justice issue in its own right. All Australians enjoy the same right to enjoy mental health, and it is appropriate for governments to address significant disparity in this area.

Social and emotional wellbeing, culture, resilience and better mental health

As noted, disadvantage and social determinants contribute to high levels of serious psychological distress among Aboriginal and Torres Strait Islander peoples. As such, efforts to address these, including through the Australian Government priority focus on unemployment, poor school attendance and unsafe communities, is an important part of working to improve mental health and related areas.

However, working to address these Australian Government priority areas without addressing mental health and social and emotional wellbeing cannot be expected to have sustainable impacts because (as discussed below) unemployment, low school attendance and community safety issues can be intertwined with mental health conditions, including substance abuse disorders.

Resilience, in particular, is critical to better mental health for Aboriginal and Torres Strait Islander peoples. Such resilience is connected to the concept of social and emotional wellbeing (SEWB). SEWB as a source of resilience can help protect against the worst impacts of stressful life events for Aboriginal and Torres Strait Islander peoples.

Aboriginal and Torres Strait Islander concepts of SEWB recognise the importance of employment, housing and education to wellbeing. However, they also include unique culturally shaped factors including the importance of culture, and cultural relationships to family and kin, community, country, and spirituality and ancestors and acknowledge their importance to the wellbeing of Aboriginal and Torres Strait Islander individuals and collectives (Gee, et al 2014).

The landmark 1995 Ways Forward report, the first national analysis of Aboriginal and Torres Strait Islander mental health, made it clear that Aboriginal and Torres Strait Islander concepts of mental health and SEWB, and the unique stressors experienced by Aboriginal and Torres Strait Islander peoples, required policy approaches to these areas that differed from those developed for non-Indigenous people.

While mental health is an important component of SEWB, it is not the sum total of it. As the National Aboriginal and Torres Strait Islander Health Plan makes clear, because of the organic

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nature of some mental health conditions, it is important to understand that a person can experience relatively strong SEWB, yet still experience mental health conditions, and vice-versa (Australian Government 2013: 20).

However, there are areas of overlap between mental health and SEWB so that an approach including both has long been considered appropriate by policy makers, especially in National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2004-2009. While never fully implemented, the Framework proved influential in shaping Aboriginal and Torres Strait Islander mental health services and programmes. The renewal of this Framework is key to the vision set out in this document.

In addition to resilience, areas of overlap between mental health and SEWB include that:

The clusters of risk factors that can weaken SEWB (for example, traumatic family and community violence) are often the same as those that increase the risk of developing mental health conditions.

Mental health conditions in family and community members can weaken individual and collective SEWB – for example, the devastating impact of substance abuse disorders and suicide as a result of mental health conditions on families and communities.

Strengthening SEWB means strengthening and supporting the families, communities and cultures of Aboriginal and Torres Strait Islander peoples. It means supporting the employment and education of Aboriginal and Torres Strait Islander people and breaking the persistent and deep disadvantage experienced by many.

Mental health and the Indigenous Affairs priorities of the Australian Government

Closing the mental health gap can be expected to make a critical contribution to achieving the COAG ‘Closing the Gap’ Target to close the gap in life expectancy by 2030:

Mental health and related conditions have been estimated to account for as much as 22% of the health gap measured in Disability Life Adjusted Years (twelve percent to mental health conditions, four percent to suicide, and six percent to alcohol and substance abuse) (Vos et al, 2007:2).

Mental health conditions are also associated with high rates of smoking (AIHW 2011), alcohol and substance abuse (ABS 2012b), and obesity (AIHW, 2011a) that, in turn contributes to chronic disease, the single biggest killer of Aboriginal and Torres Strait Islander peoples (Vos et al, 2007).

Strengthening SEWB and improving the mental health of Aboriginal and Torres Strait Islander peoples could be expected to contribute towards achieving better employment, school attendance and community safety outcomes in the following ways:

Good family functioning is an aspect of SEWB and generally associated with better outcomes for both adults and children in many areas including school attendance. In fact a recent Australian National University study found household stress, housing issues and family crises were the

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most important predictors of school non-attendance among Aboriginal and Torres Strait islander children (Biddle, 2014). This research suggests that supporting SEWB to the degree it supports and strengthens family functioning will also work to significantly reduce truancy.

Dockery’s analysis of the 2008 NATSISS reported Aboriginal and Torres Strait islander people with strong cultural attachment are significantly more likely to be in employment than those with moderate or minimal cultural attachment (Dockery 2009). Although the reasons why are not completely understood, the data suggests strengthening SEWB (cultural participation) will contribute to supporting employment outcomes.

Among adults who reported high/very high levels psychological distress in the NATSISS, 38 per cent were unable to work or carry out their normal activities for significant periods of time because of their feelings (ABS 2010). Again, while further research is needed, this suggests that a mental health condition may be contributing to the unemployment of significant numbers of Aboriginal and Torres Strait Islander people.

Violence, and alcohol related violence in particular, contributes to the burden of psychological distress experienced by Aboriginal and Torres Strait islander peoples and is a major community safety issue. It also contributes significantly to the high rates of Aboriginal and Torres Strait Islander imprisonment:

Among the Aboriginal and Torres Strait Islander prisoners in the 2014 ABS prison census, violence was the most common offence resulting in the imprisonment: with 35% being charged or convicted with acts intended to cause injury (ABS, 2014b). This compared with 16% of non-Indigenous prisoners – double the rate (ibid).

Aboriginal and Torres Strait Islander people are victims of alcohol-related violence at much higher rates than non-Indigenous people. The Australian Institute of Health and Welfare reports that in 2013 the age-standardised rate of hospitalisations for assault among Aboriginal and Torres Strait Islander peoples overall was 14 higher than that of non-Indigenous people, with the female rate 31 times higher than the rate for non-Indigenous females (AIHW, 2015).

The ABS 2013 National Drug Strategy Household Survey reported 21% of Aboriginal and Torres Strait Islander people aged 14 and over identified being the victim of alcohol-related physical abuse compared with 8.5% of non-Indigenous respondents (ibid). A 2001 study reported almost one in three homicides of Aboriginal and Torres Strait Islander people resulted from an alcohol-related incident compared to about one in ten non-Indigenous homicides (Mouzos, 2001).

High rates of mental health conditions, often co-morbid with substance abuse disorders, are reported in the Aboriginal and Torres Strait Islander prison population:

A 2008 Queensland study involved 419 Aboriginal and Torres Strait Islander prisoners being assessed for mental health conditions using assessment tools and clinical interviews conducted by Aboriginal and Torres Strait Islander mental health clinicians specific trained for the task and supported by forensic psychiatrists when indicated (Heffernan et al, 2012).

By this method, mental health conditions were detected in 73% of men and 86% of women

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(ibid). Substance abuse disorders were the most common mental health problem detected – in 66% of the men and 69% of the women assessed, often co-morbid with other mental health conditions (ibid). This was followed by anxiety disorders (20% men; 51% women); depressive disorders (11% men; 29% women); and psychotic disorders (8% men; 23% women). The 347 men involved representing 25% of all Aboriginal and Torres Strait Islander men incarcerated in Queensland, and the 72 women 62% of all Aboriginal and Torres Strait Islander women prisoners. It is the most significant study of its kind to date (ibid).

A systematic review of eight quantitative studies on the mental health of Aboriginal and Torres Strait Islander prisoners in Australia concluded that the available literature suggests high rates of mental conditions, and that the rates among women are of particular concern (Heffernan et al, 2015). However, studies in this area are few and limited in scope. The review concluded that the first step toward addressing the marked social problems and mental health conditions for Aboriginal and Torres Strait Islander people in custody is to systematically identify the nature and extent of these problems and conditions (ibid). The authors support this call.

Historically, alcohol use and substance abuse disorders are associated with offending behavior among Aboriginal and Torres Strait Islander peoples:

An analysis of Drug Use Monitoring in Australia (DUMA) project findings over 1999 – 2005 reported 79% of Aboriginal and Torres Strait Islander police detainees tested positive for drugs (including alcohol, cannabis, amphetamines and heroin) at the time of being detained by police. This compared with 67% of non- Indigenous detainees (Juodo, 2008).

The 2009 NSW Inmate Health Survey reported that 55 % of Aboriginal and Torres Strait Islander male and 64 % of female prisoners reported an association between drug use and their offence (Indig et al, 2010).

Other analysis of DUMA data (for 2002-2003) along with that from the Drug Use Careers of Offenders (DUCO) project reported over two thirds (69%) of Aboriginal and Torres Strait Islander male prisoners and 43% of male police detainees had used alcohol at the time of arrest or commission of the offence, compared with 27 % of non-Indigenous prisoners and 28% of non-Indigenous police detainees (Putt et al, 2005).

Longer-term alcohol addiction is also a contributing factor to crime. The DUCO project reported two and half times as many Aboriginal and Torres Strait Islander prisoners (5%) attributing their criminal behavior to alcohol addiction as non-Indigenous prisoners (2%) (ibid).

Recent reports suggest methamphetamine (‘Ice’) is replacing alcohol as the drug of choice in some Aboriginal and Torres Strait Islander communities (Harvey, 2015). ‘Ice’ is associated with increasing levels of violence, particularly domestic violence (ABC News, 2015).

As is clear from the above, any attempt to address Aboriginal and Torres Strait Islander imprisonment rates must include an address to mental health conditions and substance abuse disorders. And these rates are rising dramatically. In the 2014 prison census, there was a 10%

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increase in prisoners from 8,430 people in 2013, to 9,264 at 30 June 2014. This followed a 10% increase in the number of prisoners overall (ABS, 2014b). At the end of the March quarter of 2015, 9,965 Aboriginal and Torres Strait Islander prisoners were reported (ABS, 2015): approaching the grim milestone of 10,000 Aboriginal and Torres Strait Islander prisoners.

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Part 2: What has been achieved, or is in progress, in Aboriginal and Torres Strait Islander social and emotional wellbeing, mental health and related areas policy

The National Aboriginal and Torres Strait Islander Health Plan (NATSIHP)

Mental health and social and emotional wellbeing are priority areas in the NATSIHP with goals: (1) to enable ‘Aboriginal and Torres Strait Islander peoples [to] have the best possible mental health and wellbeing;’ and (2) that ‘social and emotional wellbeing strategies are integrated in all health care service delivery and health promotion strategies’ (Australian Government 2014b: 20).

The NATSIHP asserts ‘the centrality of culture and wellbeing in the health of Aboriginal and Torres Strait Islander peoples’ (ibid) and social and emotional wellbeing as ‘the foundation of Aboriginal and Torres Strait Islander physical and mental health’ (ibid: 21).

In 2014, the Australian Government announced that an implementation plan for the NATSIHP would be developed in partnership with the National Health Leadership Forum.

While the NATSIHP implementation plan touches on mental health and SEWB, a dedicated mental health plan for Aboriginal and Torres Strait Islander peoples is essential as a separate initiative. Physical and mental health are connected, but different plans are required to address both aspects in a comprehensive manner – and as for mental health, that covers the spectrum of possible mental health interventions and as have been developed for the general population. As noted in the latest draft of the NATSIHP Implementation Plan that the authors are aware of:

The Australian Government has in place, or is developing, a number of other relevant strategies which have been included in this Implementation Plan…The actions that sit under each of these strategies have not been listed however the Department and governance group that has oversight of the Implementation Plan will have a role in ensuring that there is appropriate coordination across the implementation of the strategies. This applies in particular to those strategies addressing mental health and related areas. For example, the comprehensive response to social and emotional wellbeing and mental health issues that is being developed in the National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social Wellbeing 2014 – 2019, and to drug and other alcohol issues in the Aboriginal and Torres Strait Islander peoples’ Drug Strategy, 2014-2019. Together, with the 2013 National Aboriginal and Torres Strait Islander Suicide Prevention Strategy, it is anticipated that these strategies will complement the focus on physical health in this plan. (Australian Government, 2015, unpublished).

The renewal of the National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing

In this paper, the development of a dedicated Aboriginal and Torres Strait Islander mental health plan is considered through the implementation of the renewed Social and Emotional Wellbeing Framework - a National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2004 – 2009 (SHRG 2004) (Mental Health and Social and Emotional Wellbeing Framework) that is currently being finalised.

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Action 7 of the Fourth National Mental Health Plan (2009–2014) called for the renewal of the 2004 Mental Health and Social and Emotional Wellbeing Framework. Following from this, in November 2011, the Mental Health Standing Committee of the Australian Health Ministers Advisory Council agreed to implement the above action under the auspices of the Council of Australian Governments. The current draft Mental Health and Social and Emotional Wellbeing Framework flowed from that agreement. The above was reinforced In 2012 when the Council of Australian Governments’ Roadmap for National Mental Health Reform included the renewal of the Mental Health and Social and Emotional Wellbeing Framework as one of its ten targeted strategic responses to the mental health of Aboriginal and Torres Strait Islander peoples (see also below) (COAG, 2012).

While the renewal of the Mental Health and Social and Emotional Wellbeing Framework is yet to be completed it can be expected to be the primary strategic document in relation to Aboriginal and Torres Strait Islander mental health and social and emotional wellbeing, and this paper proceeds on that basis.

ATSIMHSPAG have been closely involved in the renewal process and an in-confidence summary of the draft (as stands) is included in the text box below. It should be noted that this encompasses the spectrum of possible mental health interventions (including promotion, prevention, detection, treatment and recovery, as discussed below) and also recognises the role of strengthening SEWB as a primary mental health promotion (and to a great degree prevention) activity among Aboriginal and Torres Strait Islander peoples.

The Framework envisages a decisive shifting of emphasis in mental health policy for Aboriginal and Torres Strait Islander peoples to a promotion and preventative footing, in line with the broad findings of the National Mental Health Commissions’ National Review of Mental Health Services and Programmes (NMHC, 2014: Recommendation 7), and using SEWB to that end. This also entails a far more effective use of limited mental health resources.

A summary of the draft National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2014 – 2019

In 2013, a process to renew the 2004-2009 Mental Health and Social and Emotional Wellbeing Framework began. Currently in draft form, the renewed version to date maintains the integrated approach to mental health and SEWB of the 2004-2009 Framework. It does this throughout the spectrum of interventions within the Australian mental health system (encompassing promotion, prevention, detection, treatment and recovery). This generates five Action Areas and Strategic Directions, along with a Foundation and Supporting Action Area, as set out in the Table below.

Spectrum of interventions Action Area Strategic Directions

Foundation Action Area

1. Building an Effective and Empowered Mental Health and Social and Emotional Wellbeing Workforce

PROMOTION Action Area 1 2. A Strategy to Promote the Social and Emotional

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Strategies to Promote the Healing and Wellbeing of Communities, Families and Individuals

Wellbeing of Communities

3. A Strategy to Promote the Social and Emotional Wellbeing of Families

4. Supporting Healing Activities and Programs with a focus on Stolen Generations’ Survivors

Action Area 2Promoting Mental Health and Social and Emotional Wellbeing Across the Life Course With a Focus On Younger Age Groups

5. Promoting Mental Health and Social and Emotional Wellbeing across the Life Course with a focus on Younger Age Groups.

PREVENTION Action Area 3Prevention Strategies to Detect and Manage Risks to Mental Health

6. Developing Programs to Detect and Manage Risks to Mental Health at an Early Stage

7. Multi-disciplinary Mental Health and Social and Emotional Wellbeing Teams in Aboriginal Community Controlled Health Organisations

8. Developing Indicated Strategies for At-Risk Groups

9. Prioritising the Mental Health and Social and Emotional Wellbeing of Prisoners and Young People in Detention

TREATMENT Action Area 4Clinically and Culturally Appropriate Treatment of Mental Health Problems and Mental Illnesses

10. Assessing Mental Health Problems and Mental Illness in a Clinically and Culturally Appropriate Way

11. Increasing Access to Clinically and Culturally Appropriate Holistic Care and Treatment

12. Respecting the Human Rights of Aboriginal and Torres Strait Islander People with Severe and Ongoing Mental Illnesses

RECOVERY Action Area 5Promoting the Social and Emotional Wellbeing of those with Ongoing and Severe

13. Supporting Recovery within a Social and Emotional Wellbeing Framework

14. Supporting Aboriginal and Torres Strait Islander Carers

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Mental illnesses to Assist with Recovery and Relapse Prevention

Supporting Action Area 15. Developing a Mental Health and Social and Emotional Wellbeing Research Agenda under Aboriginal and Torres Strait Islander Leadership

In sum, the Mental Health and Social and Emotional Wellbeing Framework provides the basis for a dedicated Aboriginal and Torres Strait Islander mental health plan. This should be developed to complement the NATSIHP Implementation Plan, and in a coordinated fashion with the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy (2013) and the National Aboriginal and Torres Strait Islander Peoples’ Drug Strategy 2014-2019

A coordinated development process for the above is not only necessary to close the mental health gap, but will avoid duplication and will be more efficient. The authors note that this position is supported by the National Mental Health Commission’s Review findings (National Mental Health Commission, 2014: Vol 2, 84).

National Aboriginal and Torres Strait Islander Suicide Prevention Strategy (2013) (NATSISPS).

Suicide is a complex behaviour with many causes and is not necessarily the result of a mental health condition in all cases. Nonetheless as discussed, mental health conditions are strongly associated with suicide.

The NATSISP (Australian Government, 2013) was released in May 2013, following an extensive development process undertaken by the Aboriginal and Torres Strait Islander Suicide Prevention Advisory Group (ATSISPAG). (The authors were closely involved in this process: Professor Calma was Chair of ATSISPAG, and Professor Dudgeon a member).

The action areas of the NATSISPS are extracted in the Text Box below:

The Action Areas of National Aboriginal and Torres Strait Islander Suicide Prevention Strategy

• Action area 1: Building strengths and capacity in Aboriginal and Torres Strait Islander communities. This action area focuses on strategies to address two key areas: the encouragement of leadership, action and responsibility for suicide prevention on the part of communities; and the development, implementation and improvement of preventive services and interventions for communities and their members. The actions reflect the importance of organisations understanding communities, respecting local cultures, strengths and histories and recognising differences in social relationships and possibilities for action in rural, urban and remote settings.

• Action area 2: Building strengths and resilience in individuals and families. Suicide risk is associated with adversity in early childhood. This action area focuses on work with universal services—child and family services, schools, health services—to help build strengths and competencies and to protect against sources of risk and adversity that make children vulnerable to self-harm in later life. The focus is also on activity across

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the lifespan, directly with families or with children in schools to ensure that all Aboriginal and Torres Strait Islander children are supported to develop the social and emotional competencies that are the foundations of resilience throughout life.

• Action area 3: Targeted suicide prevention services. Targeted services are provided to individuals and families at a higher level of risk including those with mental illness, particularly those with a prior history of attempted self-harm; people in, or discharged from, custody; those with histories of alcohol and drug abuse or of domestic violence; and some people with histories of neglect and abuse. It is critically important that targeted services are well-coordinated and culturally appropriate and have access to or are followed up by culturally competent community-based preventive services. A number of strategies to address these issues are identified under this action area.

• Action area 4: Coordinating approaches to prevention. This action area relates to the importance of coordinated action of Commonwealth and state or territory governments, coordination between different departments—health, schools, justice, child and family services, child protection and housing—and coordination with the community sector to ensure that there is capacity within local Aboriginal and Torres Strait Islander organisations to provide preventive services. This will help to reduce duplication and overlap of services and to improve infrastructure and resources.

• Action area 5: Building the evidence base and disseminating information. It is important that activities to prevent suicide are founded on evidence and that services are professionally and ethically sound and do not add to the risk and vulnerability of Aboriginal and Torres Strait Islander clients. Developing a body of research in this area is a high priority. Also important are adequate data on self-harm and suicide in communities to address the gaps in the availability and accuracy of information in these areas. This action area recommends a number of strategies to address these issues.

• Action area 6: Standards and quality in suicide prevention. This action area focuses on strategies to ensure consistency in standards of practice and high quality service delivery. The three key components are: 1) Measures to improve Aboriginal and Torres Strait Islander participation in the workforce through access to training and qualifications at all levels; 2) Implementing quality controls to strengthen uptake and embedding of preventive activity in primary health care and other service sectors; and 3) Strengthening the role of evaluation to support quality implementation of programs and to evaluate their outcomes.

Coincident with the NATSISPS’s release, $17.8m funding was allocated to implementation by the Australian Government (Australian Government, 2013). The current Australian Government has indicated that the $17.8m has been quarantined to be released post release of the Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project (see below)

The Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project is currently underway, and its findings are expected to inform the NATSISPS implementation process (ATSISPEP, 2015). The ATSISPEP is due to be completed at the end of 2015.

The authors support the National Mental Health Commission’s National Review of Mental

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Health Services and Programmes call to:

Finally, implement the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy 2013, with—at least—existing funding commitments maintained and with Aboriginal and Torres Strait Islander mental health and suicide prevention leaders and stakeholders— such as the Aboriginal and Torres Strait Islander Mental Health and Suicide Prevention Advisory Group (ATSIMHSPAG)—within the broader context of the development and implementation of a dedicated national Aboriginal and Torres Strait Islander mental health plan (National Mental Health Commission, 2014: Vol 2, 118).

National Aboriginal and Torres Strait Islander Peoples’ Drug Strategy 2014-2019

The dedicated mental health plan should complement the National Aboriginal and Torres Strait Islander Peoples’ Drug Strategy under development at time of writing.

The authors support the Working Group developing the new strategy that in a paper have said that the use of alcohol, tobacco and other drugs must be addressed as part of a comprehensive, holistic approach to health ‘that includes physical, spiritual, cultural, emotional and social wellbeing, community development and capacity building’ (National Aboriginal and Torres Strait Islander Peoples’ Drug Strategy Working Group, 2013).

COAG Roadmap for National Mental Health Reform 2012-2022

In December 2012, COAG reaffirmed its commitment to mental health reform, endorsing a the Roadmap for National Mental Health Reform 2012-22 outlining the direction governments will take over the next 10 years and shaping the Fifth National Mental Health Plan currently in development.

Among 45 strategic directions, the Roadmap includes ‘targeted strategies for Aboriginal and Torres Strait Islander peoples’ including:

Targeted Strategy 5

Increase the involvement of Aboriginal and Torres Strait Islander people and their families, carers and service providers in developing and implementing culturally appropriate mental health, social and emotional wellbeing programs.

13 Support the implementation of community-led healing programs.

25 Strengthen the cultural competency of frontline professionals, including police, education and early childhood providers and healthcare professionals, to detect and appropriately intervene early in mental health concerns for Aboriginal and Torres Strait Islander people.

36 Enhance the cultural competence and training of those providing mental health services and supports to Aboriginal and Torres Strait Islander people.

37 Establish protocols for service providers working with interpreters for Aboriginal and Torres Strait Islander people.

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38 Increase and promote employment opportunities for Aboriginal and Torres Strait Islander people in mental health and social and emotional wellbeing service areas.

45 Expand the availability and ensure a range of high quality and culturally appropriate mental health services and supports for Aboriginal and Torres Strait Islander people with a mental health issue to enable their participation in education, employment and their community.

In particular, Targeted Strategy 11 is to ‘Renew and implement the National Aboriginal and Torres Strait Islander Social and Emotional Wellbeing Framework’, and Targeted Strategy 12 is to: ‘Complete and implement the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy.’

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Part 3: What Is Needed?

Improving mental health and related areas need to be made a priority of Australian Governments in their approach to Indigenous Affairs, and to be better integrated into the Indigenous Advancement Strategy and the COAG Closing the Gap Framework.

An overarching, dedicated plan of action, with an implementation plan component, that addresses in a coordinated way the following inter-related challenges among Aboriginal and Torres Strait Islander peoples:

• The high rates of mental health conditions;• The high rates of suicide; and• Alcohol and other drug use and substance abuse disorders.

The above should meaningfully connect to:

• The ongoing address to disadvantage (such as through the Indigenous Advancement Strategy and the COAG Closing the Gap Framework);

• The community controlled Aboriginal and Torres Strait Islander health services;• Mainstream mental health policy;• The ongoing effort to close the heath gap, including through the implementation of the

National Aboriginal and Torres Strait Islander Health Plan; and• Efforts to reduce the high rates of imprisonment among Aboriginal and Torres Strait Islander

peoples.

For Aboriginal and Torres Strait Islander people, achieving the above should not involve artificially separating out improving mental health and strengthening SEWB as separate domains of activity. In particular, strengthening SEWB (as a builder of resilience) should be considered a primary means of mental health promotion and prevention activity.

Aboriginal and Torres Strait Islander mental health must be addressed from a population health approach, across the spectrum of mental health interventions (as for the general population) as illustrated in the diagram below.

Diagram: The Mental Health System and the Spectrum of Interventions

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The authors support the recommendations of the National Mental Health Commission’s National Review of Mental Health Services and Programmes as summarised in the Text Box below – an extract from Volume 2 of the Review Report, (at Chapter 4, under the heading ‘Actions’).

Before reading this, please note that:

• Healthcare Management Australia (HMA) was commissioned to undertake the Aboriginal and Torres Strait Islander elements of the review for the Commission. This included reviewing the submissions received from Aboriginal and Torres Strait Islander people and organisations.

• HMA undertook their work with the oversight of a governance committee that included the authors.

• ATSIMHSPAG and the National Aboriginal and Torres Strait Islander Leadership in Mental Health (NATSILMH) also advised HMA at key junctures of the review process.

• The dedicated Aboriginal and Torres Strait Islander chapter in Volume 2 of the review (from which the text box below is extracted) closely reflects HMA’s report.

Text Box: Extract from the National Mental Health Commission’s National Review of Mental Health Services and Programmes

The Review recommends five areas to transform the mental health outcomes for Aboriginal and Torres Strait Islander peoples, and create an effective and efficient system capable of meeting need.

1. Make Aboriginal and Torres Strait Islander mental health a national priority

In Volume 1, the Review proposes making Aboriginal and Torres Strait Islander mental health a national priority and that this should be supported by agreeing an additional COAG Closing the Gap target specifically for mental health. Critically, dedicated national Aboriginal and Torres Strait Islander mental health planning and service and programme design is needed because mainstream mental health policy, service and programmes are often not culturally appropriate for Aboriginal and Torres Strait Islander people. This work would support a dedicated national Aboriginal and Torres Strait Islander mental health plan.

In doing this, it is important that Australian governments work with a credible Aboriginal and Torres Strait Islander leadership and stakeholder partnership mechanism for mental health, social and emotional wellbeing, suicide prevention, and alcohol and other drugs use prevention. The basis of this should be the Aboriginal and Torres Strait Islander Mental health and Suicide Prevention Advisory Group.

There are several components to advancing Aboriginal and Torres Strait Islander social and emotional wellbeing:

Establish mental health as a priority within the COAG Closing the Gap framework and

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within the Indigenous Advancement Strategy. Additional costs could be offset by the significant reductions in the costs associated

with addressing chronic disease, unemployment, family breakdown, alcohol and other drugs abuse, smoking, and high rates of imprisonment in Aboriginal and Torres Strait Islander peoples. In part this could occur through a justice reinvestment programme.

Achievement of this will require activation of existing frameworks for national Aboriginal and Torres Strait Islander mental health planning and service and programme design over the next 12 to 18 months through the implementation of:

the National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2014–2019

the National Aboriginal and Torres Strait Islander Health Plan 2013–2023 the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy 2013 the National Aboriginal and Torres Strait Islander Peoples’ Drug Strategy.

This will require assessment of what funding from mainstream programmes could be diverted into the new approach to offset costs. This must be subject to the outcome of individual programme reviews. All such planning must occur in partnership with Aboriginal and Torres Strait Islander peoples and under the guidance of the Aboriginal and Torres Strait Islander Mental Health and Suicide Prevention Advisory Group (ATSIMHSPAG).

Monitoring implementation of this new approach and ensuring accountability of government departments and jurisdictions for progress will be essential.

In considering the funding needs of this approach within current fiscal circumstances, the following points should be considered:

Suicide prevention expenditure should be quarantined. Funding allocated to implement the National Aboriginal and Torres Strait Islander

Suicide Prevention Strategy and the National Strategic Framework for Aboriginal and Torres Strait Islander People’s Mental Health and Social and Emotional Wellbeing 2014–2019.

Wherever possible, existing expenditure should contribute to supporting IPHCOs/ACCHS Mental Health and SEWB Teams and also specialist Aboriginal and Torres Strait Islander mental health services.

Further attention is required by mainstream services to the mental health needs of Aboriginal and Torres Strait Islander people in custodial care. A justice reinvestment programme for detainees should be introduced as a cost-effective way to reduce the risk of reoffending and minimise future custodial care outlays. It also could be extended to more youth mental health services in Aboriginal and Torres Strait Islander communities.

2. Integrated Mental Health and SEWB Teams

Require mental health and SEWB teams to be established in all government-funded IPHCOs and ACCHS, as part of renewed service agreements.

Mental health services to be fully integrated within these services as a part of their

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existing comprehensive primary health care service package. This will enable the early detection and expanded treatment of mental health problems and some mental illness in relatively inexpensive community and primary health care settings. Such mental health and SEWB teams also could help support recovery in community settings.

The integrated teams will provide access to: medical care, including pharmacotherapies and preventive health care and health

checks to promote, maintain and treat physical health structured interventions using evidence-based therapy social and cultural support, including access to housing, support with issues of

cultural identity and support from local Aboriginal people via Aboriginal health workers and Aboriginal mental health workers.

With links to: community mental health alcohol and other drugs services primary health care access to a psychiatrist mainstream services.

Workforce requirements for introducing integrated teams can be informed by planning work undertaken by the Aboriginal Medical Services Alliance Northern Territory (AMSANT).

The integrated teams would implement models of care/clinical pathways for:

community mental health—screening, treatment, support alcohol and other drugs chronic illness support SEWB promotion/community strengthening.

-3. Invigorate culturally responsive and accountable mainstream mental health services

Provide incentives and place accountability requirements on mainstream services to improve their contribution to delivering better mental health outcomes for Aboriginal and Torres Strait Islander people, including strategies such as: frameworks for policy approaches quality and professional standards with organisations such as RACGP, Australian

Practice Nurses Association and service accreditation standards agencies such as the Australian Commission on Quality and Safety in Health Care (ACSQHC)

targets and key performance indicators in funding agreements partnership agreements being established at a local level between the leadership of

mainstream services and the IPHCOs/ACCHS clinical pathways development in partnership with local ACCHOs/AMS for mental

health consumers, defining how the services will support them in their journey from primary care to acute care and the provision of on-going care for people with a chronic mental illness

professional development programmes delivered to support mainstream staff develop cultural competencies.

4. Sharpen role of dedicated Aboriginal and Torres Strait Islander services

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Refocus the role of dedicated Aboriginal and Torres Strait Islander services to support Aboriginal and Torres Strait Islander people’s journeys across the mental health system. Additional effort is needed to facilitate the journey of Aboriginal and Torres Strait Islander people into and through the specialist mental health service system, and in particular from primary mental health care settings into mainstream specialist mental health services and programmes.

Each state and territory has a different infrastructure and mix of services, so the most appropriate responses will vary. Some jurisdictions could choose to establish specialist Aboriginal and Torres Strait Islander mental health services along the lines of the Western Australia State-wide Specialist Aboriginal Mental Health Service (SSAMHS) model.

Irrespective of the precise approach, all Aboriginal and Torres Strait Islander people admitted to a specialist (mainstream) mental health service should be in the target group for this service and the following features/capabilities should be standard:

ensuring each referred/admitted person is linked from IPHCOs/ACCHS to the mainstream service and back again on discharge

cultural support during admission access to traditional healers and healing services maintaining links to family facilitation of access to community support on return to community.

5. Aboriginal and Torres Strait Islander mental health workforce development

Develop a National Aboriginal and Torres Strait Islander mental health workforce strategy to support the changes in service delivery proposed and enable all services (specialist and mainstream) to be more culturally responsive and better able to work with Aboriginal and Torres Strait Islander peoples. Key components of the strategy should include:

identifying current capacity and future workforce needs increasing opportunities for Aboriginal and Torres Strait Islander health workers to

attain advanced qualifications by strengthening educational pathways from the Vocational Education Training sector to the university sector

Increasing Aboriginal and Torres Strait Islander participation rates in tertiary courses and in the mental health workforce, involving health professional associations and education providers taking greater responsibility for increasing the level of Aboriginal and Torres Strait Islander students undertaking their courses and entering the profession. (The medical profession is demonstrating good practice in supporting the training and mentoring of Aboriginal and Torres Strait Islander medical students)

Developing specialist Aboriginal mental health courses such as the Djirruwang Programme through Charles Sturt University. This is a three-year Bachelor of Health Science (Mental Health) degree and has curricula based on workplace learning, university learning, placement learning and development of mental health competencies.

The Commission presents this report on the basis of it being implemented from within existing resources: it confirms the view that where efficiencies and savings are realised through a whole-

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of-government approach, the first priority for reinvestment should be Aboriginal and Torres Strait Islander mental health and social and emotional wellbeing.

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Conclusion

There Is a unique window of opportunity for the development of a dedicated Aboriginal and Torres Strait Islander mental health plan such as that recommended in the above Review recommendations, and that will complement the NATSIHP implementation plan.

The table below lists five strategic responses within the Aboriginal and Torres Strait Islander mental health area, or that touch on mental health. Against each is an indication of the stage of development and implementation at time of writing.

Strategic response StatusThe renewal of the Mental Health and Social and Emotional Wellbeing Framework.

Expected to be completed in 2015

National Aboriginal and Torres Strait Islander Suicide Prevention Strategy

Completed in 2013 but not yet implemented.

The Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project

To report in 2015, - the implementation of the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy is to be informed by the findings of the project

National Aboriginal and Torres Strait Islander Peoples’ Drug Strategy

Expected to be completed in 2015

General population mental health planning including the National Mental Health Plan (2009 – 14) that includes planning for mainstream mental health services that Aboriginal and Torres Strait Islander peoples use.

To be renewed probably following the Australian Government’s response to the National Mental Health Commission’s National Review of Mental Health Services and Programmes expected in early 2015.

All five strategic documents/projects are either in a late-development or pending implementation stage. Because of this, the Australian Government now enjoy a unique window of opportunity to coordinate their further development and/or implementation in an efficient and effective way. Practically, for example, this could help support the development of (to whatever degree is appropriate) integrated mental health and social and emotional wellbeing, suicide prevention and substance abuse disorder services, or promotion or prevention programs that work in all four areas simultaneously - for example through the integrated Mental Health and Social and Emotional Wellbeing Teams proposed in the Review for the Aboriginal Community Controlled Health Services, and as discussed above.

The key consideration is that just as the lived experience of Aboriginal and Torres Strait Islander people does not ‘silo’ these issues, neither should our strategic responses. A dedicated mental health plan is an opportunity to do things differently, to work across a number of areas to close the mental health gap, and work to dramatically improve the mental health and physical health and lives of Aboriginal and Torres Strait Islander peoples. Such a plan will also support the achievement of the priority Indigenous Affairs goals of the Australian Government.

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