4. Mental Health, Cognitive Health, Trauma and Substance Misuse
The interconnected nature of Brain health requires a very different approach to assessment and supports..
Aboriginal understandings of mental health are grounded in the guiding health concept of Social and Emotional Well-being (SEWB). The concept acknowledges connectedness, holistic ideas of health and the impacts of trauma and loss, and of Aboriginal rights and strengths.
Past detailed studies of the mental health of prisoners in New South Wales have shown very high levels of mental health problems, with up to 80% of prisoners having experienced any psychiatric illness in the past 12 months. Rates of psychosis, substance use disorders, personality disorders and head injury in prisoners were all 8-12 times higher than average community rates. [Butler et al]
The health of our brains is shaped and sustained by a range of interconnected factors that determine how we respond to the world around us.
In our whitefella world, when we talk about mental health we are describing only one part of the story. More recently people have started talking about ‘Brain Health’ in an attempt to talk more inclusively about what shapes our mental, cognitive and emotional wellbeing.
The adjacent diagram, illustrates a ‘trans-diagnostic’ view of Brain Health. It attempts to convey some of the interconnected, mutually reinforcing, frequently co-existing domains that shape the whitefella diagnostic view of our mental functioning. All four domains impact on our overall cognitive functioning, particularly affecting the pre-frontal cortex of the brain, responsible for decision-making and problem-solving, affecting how a person responds to their outside world.
For Aboriginal communities, co-morbidity and complexity are often the norm, and diagnostic clarity may be difficult to achieve. Cultural and social disconnection, socioeconomic disadvantage and justice involvement further compound the picture.
While the diagram itself is not surprising, one of the main challenges here is that each of the four domains is managed by a different mainstream service sector, each with its own specialty approaches to treatment and care.
Mainstreaming for Aboriginal prisoners just doesn’t work.
On release, prisoners are commonly referred to multiple services for follow-up, each acting independently of the others, setting up an entirely unrealistic and unhelpful response plan, particularly if the client is already homeless on release. On top of Centrelink, housing services and community corrections appointments, a person can be referred to attend mental health, drug counselling and disability supports. Each appointment can require several public transport trips. For most, the person in the middle and their family risk being overwhelmed with ‘help’ that is not integrated and is ultimately confusing and counter-productive. Then, there is the too common practice of blaming the client if they do not engage. For some, non-engagement results in return to prison.
At the other end of the spectrum there is the risk for clients with prison histories and complex needs being excluded entirely from services because of their complexity and concerns about perceived risks to staff, often without the necessary information available to assess risk. People can be shunted around the systems without ever getting the support they need.
Too often prisoners are ‘risk-managed out of care.’
Acquired Brain Injury (ABI):
Australian research studies indicate that around 42% of men in prison and 33% of women in prison have an Acquired Brain Injury, compared with 2% in the community. The factors that lead to an increased risk of ABI can overlap with factors that lead to aimprisonment, for example early exposure to traumatic stress; leaving education early; risk-taking behaviour early in life; homelessness and its associated vulnerabilities; continued misuse of alcohol or other drugs and exposure to violence in intimate relationships.
ABI can result in multiple disabilities arising from damage to the brain after birth. It is often called the invisible injury, because many people with an ABI do not have obvious physical impairments. Symptoms of ABI vary greatly from one person to the next; they can include physical, emotional, behavioural, language and cognitive difficulties. ABI can be caused by an injury to the head, medical conditions affecting the brain; low oxygen to the brain or long-term, heavy drug or alcohol use.
Traumatic Stress, Complex Trauma and Collective Trauma: Aboriginal communities have continually described the ongoing impacts of both historical and contemporary traumatic experience ever since colonisation. The consequences of complex and collectively experienced trauma affect the daily lives of individuals and whole communities. Traumatic experience can compound psychosocial impairment from other causes and greatly impact on a person’s capacity to function well in their community. Symptoms like anxiety and depression, suicidal ideation, anger, aggression can all be expressions of traumatic stress. Creating safe, nurturing, communities is an essential step in healing from trauma.
Prisons are also an independent risk factor for suicide, as is the immediate post-release period. Showing vulnerability of any kind in prison places a prisoner at risk of harm. For Australians between the ages of 15 and 44 years, suicide is the leading cause of death (AIHW, 2022a). The suicide rate in Aboriginal and Torres Strait Islander peoples is twice that of their non-Indigenous counterparts (ABS, 2022).
Providing the right integrated services to respond to the complex brain health needs of prisoners is skilled work. Prisoners, offenders and indeed most of us, need a single point of contact where practitioner teams can respond to all areas of brain health. Our artificial divisions between mental health, drug use, trauma and cognitive problems result in inefficient systems that just can’t adequately serve community needs, let alone meet cultural needs.
We require skilled well-resourced, culturally-safe teams embedded within Aboriginal-controlled community-based services across the country.
More to follow on this soon.
The Brain Health Complex
One of the main challenges here is that each of the four domains is managed by a different mainstream service sector, each with its own specialty approaches to treatment and care.
Some Brain Health Facts
Up to 40% of victims of family violence attending hospital sustain a Brain Injury.
People with Post-Traumatic Stress experience significantly higher rates of psychosis when compared to the wider community.
Over 60% of people in prison are estimated to have an Acquired Brain Injury.
Life expectancy for people with major Mental Health issues is 10-20 years less than the general population, mostly due to physical comorbidities, particularly diabetes and cardiovascular disease. Much of this gap is preventable.
People with major traumatic childhood adverse events have worse physical health later in life and a decreased life expectancy.
1. Brain Injury Australia The Prevalence of Acquired Brain Injury Among Victims and Perpetrators of Family Violence Brain Injury Australia 2018
2. Seedat, S et al Linking Posttraumatic Stress Disorder and Psychosis: A Look at Epidemiology, Phenomenology, and Treatment. The Journal of Nervous and Mental Disease Vol 191:10. October 2003.
3. Jesuit Social Services /RMIT Enabling Justice Project Consultation paper: People living with Acquired brain injury using their experiences of the criminal justice system to achieve systemic change. June 2016.
4. Firth, J et al The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness.The Lancet Psychiatry Commission Vol 6 :8 Aug 2019 pp675-712.
5. American Academy of Pediatrics Adverse Childhood Experiences and the Lifelong Consequences of Trauma 2014 Accessed at: https://www.aap.org/en-us/Documents/ttb_aces_consequences.pdf