Thread by @coopesdetat

Greatly looking forward to the next two sessions at #RANZCP2021 on Maori and Aboriginal and Torres Strait Islander mental health, feat Helen Milroy (WA Australian of the Year and Australia's first-ever Indigenous MD), Allister Bush, Mark Lawrence & Wiremu NiaNia

First up Palyku woman Helen Milroy, paying respects to elders. Will be speaking about complexities in Aboriginal MH #RANZCP2021

How do cultural perspectives cross over with illness experiences? Milroy sharing some examples #RANZCP2021

Historical legacy brings many complicating factors says Milroy. Normalising of trauma and retraumatisation, fear of not being understood from a cultural perspective, pathologised #RANZCP2021

Kinship brings another layer of complexity, and should be understood in a treatment context #RANZCP2021

Paranormal phenomena, cultural explanations can be misunderstood. Some things are taboo and cannot be disclosed. Traditional healing has had a role for many generations. Some cultural issues require a cultural solution #RANZCP2021

Not many valid assessment tools at present, Milroy says. Very subjective, adapting Western models a poor fit, biased by background of assessor. Eye contact and rapport one commonly misunderstood issue #RANZCP2021

She notes a paucity of evidence on treatment efficacy specific to Indigenous peoples, in view of the particular biological and cultural drivers #RANZCP2021

Some phenomena are normal in cultural terms, but pathologised by Western medicine, Milroy says. Flip side - cannot always dismiss as normal and not illness, important to delve into person's context #RANZCP2021

Illness in this context can also respond to and require non-illness treatments eg connection to country. Milroy says each cultural group will have specific understandings #RANZCP2021

Position as post-genocide population in a post-colonial society put Aboriginal and Torres Strait Islander people in a unique position. Unfinished business in this space like land rights have a significant impact on MH #RANZCP2021

Milroy speaks to importance of strengths-based models, healing rather than recovery and risk. A language gap exists. Strength and gentleness at same time #RANZCP2021

If you don't know how to walk in a cross-cultural context then you cannot know what you are doing, especially in a subjective space like mental health. Need an Aboriginal frame of reference, Milroy says. Psychiatry cannot hold all the answers #RANZCP2021

Important considerations. You must understand history, impact of trauma, grief and loss, power says Milroy. Where have connections been lost that you can restore? Trauma not often spoke of, normalised, but a huge role. Treatments out of the box, opinions of elders #RANZCP2021

Don't assume what depression and psychosis is in the Indigenous context until you have lots of experience. The cultural aspects of a presentation must be checked with the original group. If you don't know, get help, never just treat #RANZCP2021

Allister Bush & Wiremu NiaNia up next on New Zealand experiences #RANZCP2021

NiaNia starts with a karakia on the pathway of ranginui - "everything on Earth needs the sun" #RANZCP2021

Bush acknowledges the elders of Te Whare Marie and the young people who have shared their experiences #ranzcp2021

Bush talking about importance of cultural expertise in assessing a patient and the fact this kind of knowledge has historically been disregarded by psychiatry and eroded by colonisation #RANZCP2021

First thing to remember is to use appropriate (Kaupapa Maori) customs and protocol to demonstrate respect (manaaki). Understand someone in the context of family (whanau). Give mana. Realise that psychiatry has contributed to silencing Indigenous peoples #RANZCP2021

Consider whether something could have a cultural meaning and seek advice #RANZCP2021

NiaNia says never discount statements on what people are seeing and hearing. Remembers seeing 'Jake' with Bush and seeing a striking woman in the room. Describing her, Jake said that was his grandmother #RANZCP2021

Consider the prospect that someone could have matekite (seer or medium), says NiaNia. Does a voice come with a presence? A vision? Intuition? Does this date back to childhood? Is there family hx? Does anyone share their perceptions? #RANZCP2021

A case of cultural/spiritual experiences being the best explanation for a presentation #RANZCP2021

Interesting questions to consider to tease out Mate Maori/Mate Wairua (Maori spiritual/cultural problems). Substance use can open doorway to a spiritual realm says NiaNia #RANZCP2021

NiaNia says it is important to differentiate between problems arising from the ancestors (mate Maori) and cultural/spiritual problems that do not fit that criteria (trauma, loss, grief, abandonment) #RANZCP2021

How do we adapt our practice to bring cultural practice and frameworks into mainstream services, asks chair Marshall Watson. Milroy says we have a long way to go to this, need to build up and showcase evidence base. And greater cultural safety needed as starting point #RANZCP2021

NiaNia says answers to this question should already be known. About respect, deference. He pays tribute to Australia's tangata whenua, the original inhabitants, and says we all have much to learn from them, oldest cultures in the world #RANZCP2021

Bush reflecting on systemic barriers, reluctance to engage with and employ tohunga (Maori healers) #RANZCP2021

Milroy says it isn't about saying psychosis is never relevant, but that it is too hastily arrived at as a diagnosis when trauma or cultural context may be a better fit. About healing rather than symptom control #RANZCP2021

Bush says it should be possible for psychiatrists to hold several ideas in the frame at once & engage in watchful waiting with clients, offer different strategies and constantly review and revisit across the realms of psychosis, spiritual experiences, culture & trauma #RANZCP2021

That's a wrap on session one, we will be back at 3 for the second session, stay tuned! #RANZCP2021

Underway with our second part: clinical update in Indigenous mental health. Helen Milroy back with us first, followed by Mark Lawrence. Chair is Sue Mackersey #RANZCP2021

Milroy says the policy & clinical landscape has changed dramatically. MH finally come centre-stage. Increased advocacy in Indigenous MH space, more orgs, greater capacity for partnership, diversity of voices #RANZCP2021

Many unresolved issues including lack of services esp for rural areas, child & adolescent, cultural safety #RANZCP2021

Milroy speaking about @GayaaDhuwi. Featuring reps from @cbpatsisp, @NACCHOAustralia, @AIDAAustralia & others. Read the declaration here #RANZCP2021 natsilmh.org.au/sites/default/…

Milroy also points to Coalition of Peaks as a game-changer for relations with government, a unified voice, clearing house for advice and knowledge. Health, mental health, #SDOH. Design, delivery and decision making #RANZCP2021

Says a glass ceiling remains but there is a much better platform now for making mutual decisions. Also points to a rise of professional bodies - reduces fragmentation and opinion-shopping. Pays tribute to @cbpatsisp, @lowitjainst #RANZCP2021

#RANZCP2021

Greater emphasis on Indigenous governance, longer 10-year policy cycles says Milroy. SEWB & suicide prevention big unfinished pieces of work #RANZCP2021

Interface between primary care, SEWB & mainstream MH - lack of cohesion and collaboration a major and persisting issue for Aboriginal and Torres Strait Islander groups. Huge problems in cultural safety, exclusion, validity of tools and outcome measures #RANZCP2021

Lacking a dedicated workforce development strategy, no upskilling or development pathway for (and reliance on) lowly-paid Aboriginal staff, says Milroy #RANZCP2021

WA inquiry report in 2020 found Aboriginal consumers not consistently being offered their rights. When you even have it in legislation, it just doesn't happen. What are the barriers? No community involvement or partnership, few AHWs with relevant training #RANZCP2021

Great progress in some areas, others getting worse. Improvements still slow, even with relevant policy in place. 'I don't know what it is going to take but we can't allow this to continue at risk of losing generations to out of home care, juvenile justice & suicide' #RANZCP2021

We have come a long way I don't doubt it there is a lot of promise and there is a lot of goodwill, but there is still so much to be done says Milroy. Closing with sentiments from Tom Calma she says still ring true today #RANZCP2021

The way forward is genuine partnership, no longer sufficient to have champions, it must be built into service provision model. Historical trauma casting a shadow and one of the things we can actually shift by engaging with it #RANZCP2021

Milroy says despite cultural diversity across Australia there is a lot of commonality for Indigenous groups - esp around magnitude of trauma and displacement experienced. Hard to get a truly representative group due to sheer numbers, but there is common ground #RANZCP2021

What could cultural outcome measures look like? Milroy says we need to understand what is meaningful from an Aboriginal perspective and how meaning is made - art, story, performance #RANZCP2021

Mark Lawrence up now, on decolonising experiences in Aotearoa #RANZCP2021

#COVID19 has had many lessons. Chief among them - we can adapt says Lawrence #RANZCP2021

Love this from Mark Lawrence. Australia, in te reo: whenua moemoea, the land of the dreaming. Speaking of the importance of land - whenua - to Maori #RANZCP2021

The land gives us status, says Lawrence. If we don't have land we don't have authority #RANZCP2021

Colonisation has no end point, says Lawrence. Its consequences are ongoing #RANZCP2021

"A lie doesn't become truth, wrong doesn't become right just because it is accepted by a majority" says Lawrence, quoting Moana Jackson on the mythical reconstruction of Maori post-colonisation #RANZCP2021

Really interesting to hear about Te Reo Hapai, a book translating MH terms. Some lovely examples #RANZCP2021

Loving this reflection from Mark Lawrence on translating manaaki-tanga to the clinical space, observing the same protocols to make a sanctuary such as marae safe for visitors #RANZCP2021

Lawrence says you must see patients in the longitudinal, appreciate their experiences, to understand #RANZCP2021

Lawrence says establishment of an independent Maori Health Authority is hugely significant, led by Mason Durie #RANZCP2021

Decolonisation - truth-telling, postive change, relearning, achieving equity. Structures must change to reflect the place and people of that place. It's your legacy, it's my legacy. Tremendous will politically & in medicine in NZ: be part of the change #RANZCP2021

We need to look back to see our future, concludes Lawrence #RANZCP2021

NZ has just reached population parity for Maori graduates from its two medical schools, but Lawrence says this is the culmination of about a decade of work and Pakeha buy-in #RANZCP2021

Biggest thing non-Indigenous people working in the MH space can do? Listen, says Lawrence. And when you are out of your depth, seek advice and support #RANZCP2021