“Two Angels” by Suzanne Schneider
By Dr Paul Brown, The Pierre Janet Centre, Melbourne.
In my sojourn as a locum psychiatrist in rural and remote Australia, I was astonished at the rate of diagnosis of schizophrenia in indigenous populations. That condition is characterised by, “abnormal social behaviour and failure to recognize what is real,”[1] and with symptoms that include confused thinking, hallucinations, delusions, social withdrawal and emotional blunting. It is associated with increased rates of suicide and homicide. Schizophrenia is said to have been rare in the pre-colonial era. Today, in indigenous communities, mental disorder is still frequently identified as spiritual disorder.[2] It is treated by traditional healers, often concurrently, alongside Western medical practitioners.
Today schizophrenia is said to be at least as common in Aborigines as in white Australians, if not more so. It and mental illness in general, is said to be under-estimated.[3] A not insignificant proportion of psychosis is to be found in prisons. Indigenous people represent around one-quarter of Australia’s custodial population. In recent prison surveys of Aboriginal prisoners, [4] [5] the 12-month prevalence of psychotic disorders was: men, 8%; and, women, 23%. The overall prevalence of mental disorder was: 73% among men and 86% among women. Non-psychotic conditions comprised: anxiety disorders (men, 20%; women, 51%); depressive disorders (men, 11%; women, 29%); and substance misuse disorders (men, 66%; women, 69%).
In no small part schizophrenia in Aborigines has been attributed to the post-colonial epidemic of substance abuse afflicting indigenous peoples. However, there are additional explanations for psychosis in Aboriginals, and alternative differential diagnoses. The most important of these is rarely considered, namely stress, and traumatic stress presenting, not as the present zeitgeist, post-traumatic stress disorder (itself of questionable validity), but as depressive psychosis in both its unipolar and bipolar forms. Stimulant abuse appears to be especially associated with the latter.[6] Head injury also plays a part. More importantly, there is the metabolic syndrome, with the neuropsychiatric complications of diabetes, hypertension and heart disease.[7] [8] [9] [10]
First I must say a few words about psychosis. It is not what it was! After a hundred years of occidental, scientific study, the professional psychiatric community became convinced of the stability of the three principal diagnoses of psychosis: organic, principally as dementia; schizophreniform; and, affective. Cracks then began to appear in the psychopathological edifice. Schizophrenia became clinically milder, and recrudescence was more prominently accompanied by affective disorder leading to an increased diagnosis of schizoaffective disorder. The latter was mostly attributed to increased, depressive affectivity in the context of a schizophreniform psychosis. But prior to that affectivity was a bed-rock of environmental, psychosocial stress sensitivity. Further, the alternative diagnosis of bipolar affective disorder (manic depression) was rarely considered in Aboriginal communities. There is no scientific literature on it![11]
Today, the stability of the psychosis triumvirate is increasingly questioned by the experts. Rather than discrete disease types, they are seen as the symptomatic (phenotypic) presentation of a very wide range of different organic, affective and schizophreniform pathophysiologies, and varying causal proportions of nature and nurture. Further, it is well accepted that psychosis in psychiatric illness is on a continuum with normality.[12] Psychotic phenomena, including hallucinations and delusions, are prosaic phenomena. They can accompany the exhaustion of sleeplessness, the delirium of an ordinary influenza, and a blow to the head.
So, what is the true psychiatric situation in the aboriginal community? Hunter[13] wrote, “Indigenous Australians have higher rates of serious mental disorders and of mental health problems associated with social disadvantage … compounded by narrowly focused and inadequate mental health services … with children being particularly vulnerable.” Primary prevention is in its infancy.[14] It is mostly carried out by dedicated white Australians, without either special knowledge of Aboriginal culture, or of mental health, Aboriginal or otherwise.
Culturally sensitive community surveys of diagnosis and treatment of psychiatric illness are in their infancy. Methodologies of mental assessment suitable for Indigenous Australians are only just being developed for adults,[15] and for children and youth.[16] A review of eleven Indigenous community surveys found a higher prevalence of self-reported psychological distress.[17] But the distress of Indigenous Australians is not necessarily expressed in the same way as in the non-Indigenous. A cross-cultural study of schizophrenia found that, at the very least, bizarre delusions, social deterioration, illness duration and organicity differentiated Aboriginal from non-Indigenous subjects.[18]
A comprehensive overview of Indigenous health is provided on-line by Deakin University.[19] Mental and behavioural disorders, and circulatory diseases, affect the community equally (5.7%). The only conditions that were more common, were: injury (including motor-vehicle accidents, assaults, self-inflicted harm, and falls) and poisoning (13.9%); pregnancy-related (12.6%); respiratory diseases (11.3%); and, digestive diseases (8.6%). Indigenous adults were almost 1½ times more likely to report experiencing at least one stressor than non-Indigenous people, and the stressors reported most frequently by Indigenous people were death of a family member or close friend (46%), serious illness or disability (31%), and inability to get a job (27%). Hospitalisation for substance abuse was 3 (female) to 4 (male) times higher for Indigenous people, and rates for schizophrenia were more than double that for non-Indigenous subjects. The Indigenous mortality due to suicide was 2- (female) to 5-times (male) higher than the non-Indigenous population, with high rates amongst youth. Socio-historical, causal factors have been cited.[20]
My own impression is that schizophrenia is over-diagnosed and over-treated at the expense of the diagnosis of stress-induced conditions, and especially the whole range of unipolar and bipolar affective conditions. These include both stress- and non-stress induced forms, substance abuse related forms, and those due to metabolic disease and head injury. The treatment consequences are catastrophic. Sufferers from severe mood disorders are denied antidepressants, and mood stabilisers. Instead they receive antipsychotics which mask the affective symptomatology. Those with organic conditions are denied appropriate medical treatment and rehabilitation. Currently, there is a professional movement for early intervention in psychosis. It is contentious, because mis-diagnosis and over-treatment have fateful consequences. How much more so in Aboriginal populations at risk?![21]
Teasedale[22] recently wrote, “Few data are available on how mainstream drug and alcohol services meet the needs of Aboriginal Australians. Youth are increasingly prone to polydrug abuse. Solvent inhalation is an especially deadly problem. Hunter[23] surveyed alcohol and drug abuse in the Indigenous population of the Kimberleys. Knowledge of this topic is essential, not only in the treatment and prevention of substance abuse, but also in the management of psychosis, since this is often complicated by the use of drugs and alcohol. Hunter found that Aborigines in the Kimberley were less often problem drinkers than the general population, but drinkers were much more likely to drink hazardous amounts.
The pan-Australian split between psychiatric services, and treatment facilities for substance abuse, has been catastrophic. Substance abuse is under-diagnosed and under-treated in mental health facilities, and psychiatric disorder under-diagnosed and under-treated in substance abuse facilities. The net result has been a de-skilling of the whole field vis-à-vis substance abuse and mental illness. Nonetheless, screening tools are in the pipeline for measuring relationships between substance use and psychiatric symptoms in Indigenous Australians,[24] including in prison populations.[25] [26]
Once, psychiatric wards and hospitals were museums of madness.[27] Symptoms and signs of mental illness were freely displayed. In the old world, the hoy polloy even came to observe the antics of the insane. The more ‘enlightened’ asylum administrations, most famously at Charenton, in France, even trained the inmates to put on pageants and shows. This was even the subject of a contemporary stage production.[28] With the advent of psychotropic medications, a medical straightjacket was slowly but inexorably applied to the insane. The psychiatric potions were not curative. Rather they controlled symptoms, and perhaps facilitated natural recovery.
Today, psychiatric wards are mausoleums of madness. Dosages of psychotropic medications now far exceed those used by previous generations of psychiatrists. The risk of dangerous side-effects, such as tardive dyskinesia and the neuroleptic malignant syndrome, are frequently disregarded. Wards are now quiet places, and psychiatric patients, both Indigenous and non-Indigenous, are only transitorily out of control. They transition from what are called high dependency units to open wards. A generation ago, the latter were busy paces, where the medicated also had access to milieu therapies ranging from group therapy to occupational therapy, art therapy, and activity therapies. Today, these treatments have been phased out. Non-medical therapies are deemed costly and ineffective. The medical model, managerialism and fiscal restraint are regnant.
In mental health for Indigenous subjects, there is a great divide between social activists and the social sciences, and medical activists and the medial sciences. The report, Mental Health and Social and Emotional Wellbeing of Aboriginal and Torres Strait Islander Peoples, Families and Communities (2013), is unlikely to make a difference in the clinical field. Its approach and its vernacular, speak to Westernised, non-clinical conceptualisations. Further, true psychiatric research vis-à-vis the Indigenous populations has hardly reached the coal-face. Mental health clinicians remain far removed from the activists and researchers. A ground-roots movement is required, led by aboriginal psychiatrists and mental health workers,[29] [30] and funded by the Aboriginal community. It must look after its own, in liaison with mainstream white Australian psychiatry and medicine.[31] Only then will the superficial and often culturally inappropriate regimes characterised by paternalistic academic and professional styles, be forestalled.
[1] Schizophrenia. http://en.wikipedia.org/wiki/Schizophrenia.
[2] Moffatt LL. Mental illness or spiritual illness: what should we call it? Med J Aust, 2011; 194: 541-2.
[3] Haswell-Elkins M Sebasio T Hunter E Mar M. Challenges of measuring the mental health of Indigenous Australians: honouring ethical expectations and driving greater accuracy. Australas Psychiatry, 2007; 15 Suppl 1:S29-33.
[4] Heffernan E Andersen K Kinner S. The insidious problem inside: mental health problems of Aboriginal and Torres Strait Islander People in custody. Australas Psychiatry, 2009; 17 Suppl 1: S41-6. doi: 10.1080/10398560902948696.
[5] Heffernan EB Andersen KC Dev A Kinner S. Prevalence of mental illness among Aboriginal and Torres Strait Islander people in Queensland prisons. Med J Aust, 2012; 197: 37-41.
[6] Sara GE Burgess PM Malhi GS Whiteford HA Hall WC. The impact of cannabis and stimulant disorders on diagnostic stability in psychosis. J Clin Psychiatry, 2014; 75: 349-56. doi: 10.4088/JCP.13m08878.
[7] Edwards FM, Wise PH, Thomas DW, Murchland JB, Craig RJ. Blood pressures and electrocardiographic findings in the South Australian Aborigines. Aust N Z J Med. 1976 Jun;6(3):197-205.
[8] Bastian P. Coronary heart disease in tribal Aborigines:the West Kimberley survey. Aust N Z J Med, 1979; 9: 284-92.
[9] Smith RM Spargo RM King RA Hunter EM Correll RL Nestel PJ. Risk factors for hypertension in Kimberley aborigines. Med J Aust, 1992; 156: 562-6.
[10] Smith RM Spargo RM Hunter EM King RA Correll RL Craig IH Nestel PJ. Prevalence of hypertension in Kimberley aborigines and its relationship to ischaemic heart disease. An age-stratified random survey. Med J Aust, 1992; 156: 557-62.
[11] Parker R. Mental illness in Aboriginal and Torres Strait Islander peoples. Chapter 5, in Working together. http://creahw.org.au/media/54871/chapter5.pdf
[12] Hanssen M Bak M Bijl R Vollebergh W van Os J. The incidence and outcome of subclinical psychotic experiences in the general population. Br J Clin Psychol, 2005; 44: 181-91.
[13] Hunter E. Disadvantage and discontent: a review of issues relevant to the mental health of rural and remote Indigenous Australians. Aust J Rural Health, 2007; 15: 88-93.
[14] Hunter E. Is there a role for prevention in aboriginal mental health? Aust J Public Health, 1995; 19: 573-9.
[15] Dingwall KM Cairney S. Psychological and cognitive assessment of Indigenous Australians. Aust N Z J Psychiatry, 2010; 44: 20-30. doi: 10.3109/00048670903393670.
[16] Thomas A Cairney S Gunthorpe W Paradies Y Sayers S. Strong Souls: development and validation of a culturally appropriate tool for assessment of social and emotional well-being in Indigenous youth. Aust N Z J Psychiatry, 2010; 44: 40-8. doi: 10.3109/00048670903393589.
[17] Jorm AF Bourchier SJ Cvetkovski S Stewart G. Mental health of Indigenous Australians: a review of findings from community surveys. Med J Aust, 2012; 196: 118-21.
[18] Mowry BJ Lennon DP De Felice CN. Diagnosis of schizophrenia in a matched sample of Australian aborigines. Acta Psychiatr Scand, 1994; 90: 337-41.
[19] Overview of Australian indigenous health, 2008. Deakin University, Department of Rural Health. http://www.greaterhealth.org/education-training/indigenoushealth/illhealth/
[20] Hunter E. Using a socio-historical frame to analyse aboriginal self-destructive behaviour. Aust N Z J Psychiatry, 1990; 24: 191-8.
[21] Catts S O’Toole B Neil A Harris M Frost A Eadie K Evans R Crissman B McClay J Shorey T. Best practice in early psychosis intervention for Australian indigenous communities: indigenous worker consultation and service model description. Australas Psychiatry, 2013; 21: 249-53. doi: 10.1177/1039856213480532. Epub 2013 Apr 24.
[22] Teasdale KE Conigrave KM Kiel KA Freeburn B Long G Becker K. Improving services for prevention and treatment of substance misuse for Aboriginal communities in a Sydney Area Health Service. Drug Alcohol Rev, 2008; 27: 152-9. doi: 10.1080/09595230701829447.
[23] Hunter EM Hall WD Spargo RM. Patterns of alcohol consumption in the Kimberley aboriginal population. Med J Aust, 1992; 156: 764-8.
[24] Dingwall KM Cairney S. Detecting psychological symptoms related to substance use among Indigenous Australians. Drug Alcohol Rev, 2011; 30: 33-9. doi: 10.1111/j.1465-3362.2010.00194.x.
[25] Schlesinger CM Ober C McCarthy MM Watson JD Seinen A. The development and validation of the Indigenous Risk Impact Screen (IRIS): a 13-item screening instrument for alcohol and drug and mental health risk. Drug Alcohol Rev, 2007; 26: 109-17.
[26] Ober C Dingle K Clavarino A Najman JM Alati R Heffernan EB. Validating a screening tool for mental health and substance use risk in an Indigenous prison population. Drug Alcohol Rev, 2013; 32: 611-7. doi: 10.1111/dar.12063. Epub 2013 Jun 27.
[27] Scull ET. Museums of madness: the social organization of insanity in nineteenth-century England. London:. Allen Lane, 1979.
[28] Weiss P. The persecution and assassination of Jean-Paul Marat as performed by the inmates of the Asylum of Charenton under the direction of the Marquis De Sade. London: John Calder, 1964.
[29] Spencer DJ. Psychiatric dilemmas in Australian aborigines. Int J Soc Psychiatry, 1983; 29: 208-14.
[30] Kowanko I de Crespigny C Murray H Groenkjaer M Emden C. Better medication management for Aboriginal people with mental health disorders: a survey of providers. Aust J Rural Health, 2004; 12: 253-7.
[31] Brown R. Australian Indigenous mental health. Aust N Z J Ment Health Nursing, 2001; 10: 33-41.
Once a psychiatrist told me that basic belief in traditional indigenous culture, was the same as having schizophrenia. It was a little difficult, at the time, in the patient’s chair, to present a coherent academic argument against his point of view, but I wanted to. I wanted to tell him that a vast difference exists between the sanity of the code of conduct of traditional indigenous kinship, and the anathema of loss of culture, masqueraded as cultural, among many indigenous persons who had “done time” as they say, in the prisons. Thankfully early on in my developing PTSD symptoms, (connected with a natural disaster), a health care professional recommended I read a book named “The Stormy Search For Self”, by Christina Grof with her psychiatrist husband, Stanislav Grof. While I don’t agree with the kind of ” breath work” the Grof’s do (in lieu of legal access to psychedelic/hallucinagenic plants for the medicinal value), Stanislav Grof’s checklist for whether it is safe to explore one’s internal psychology by acting out aspects of psychosis when safe to do so, turned out to be a Godsend, that helped me stay stable on the inside, with stable emotions, and clean of drugs etc, while my life just kind of fell apart awhile, until I got on top of the PTSD… All along, through ten odd years of occasional episodes (twice a year at most, and in no regular pattern, lasting only a week or two each time), of PTSD symptoms, I could hold sympathy for the plight of many with PTSD born in the prisons, and out of stolen generations. I didn’t yet read the DSM 5, but am presuming that since the article here stated PTSD was not yet an accepted diagnosis, (there were different versions of what the diagnosis was, and that maybe why: eg the original diagnosis was from work with Vietnam vets in Australia, and defined PTSD as a recoverable diagnosis, BUT, the kind of PTSD that enabled financial payouts to Native Americans because of residential school trauma, was not recoverable), there is a way to go yet, before the anaylsis of “Dissociative Identity Disorder spectrum” (aka DIDs), comes together with work such as that of clinical psychologist Dr Tracey Westerman, in proving Traditional Idigenous Australian medicine men, are competent and skilled in handling PTSD symptoms, if only it is not everybody suffering the trauma. Dissociative psychosis is the clinical name for the kind of mental symptoms of PTSD, and worse conditions, like full blown multiple personality disorder, (I know of examples of among former prison inmates, which were only triggered in criminal contexts). And is different, but could seem similar, to the disease symptoms associated with breaking traditional kinship.
P.S. I wholeheartedly agree with the article above, in what it is saying about not enough shared grounds between mental health work, and addiction treatment work. I support the twelve step programme, and I believe the programme could readily be adopted, and adapted, within traditional kinship contexts. I also think that the loss of culture in the prisons, where falsifications of initiatory rituals were regular, caused a specific kind of pattern of mental ill health, associated with cultural alienation. But because the symptoms were often hand in hand with drug abuse, it could be hard to identify the symptom pattern. A strong trait however, was lacking motivation to get clean from drugs, because of an underlying fear, that what indigenous former prison inmates all imagined was a victory of sorts won in the prisons, might all come unstuck, if without drugs. I know men who, every time they started detoxing, were frightened that they hand played the wrong hand in connection with prison time.
I am a carer full time for my mother who has had a schizo effective disorder or schizophrenia for more than 18 years.
I live in Scarborough and there is a local aboriginal lady who is homeless but lives here, she has been here for as long as I’ve been here which is over 6 years.
She does all of the bad things, she drinks and can’t keep a home and according to the mental health service when I called them she doesn’t stay on a treatment schedule. I see her all the time talking to people that aren’t there and behaving inappropriately at the supermarket etc.
All of the locals know her and accept her but because this is a holiday suburb strangers come all the time and beat her and strangle her pets ie rabbits etc.
She no longer has a trolley because the supermarkets have all put brakes on them so now she carries around a very large wine soaked suitcase.
I was getting the bus back home the other night and she was as drunk as a skunk with some sort of goon concoction in a cup at the station.
Her demeanor was pleasant enough. She couldn’t get her enormous suitcase onto the bus and the driver, an indian, didn’t want her to get on. She was asking people to help and everyone just gave her filthy looks.
The bus driver refused to lower the ramp for her to pull her suitcase on. So I had o manually go and bend down and lift the massive suitcase while she was drunkenly trying to pull it onto the bus.
My point is this. Community service providers such as transport ie taxi and bus should be helping the disabled. They put a ramp down for a wheelchair or pram but not for a schizophrenic that probably didn’t even know where she was. or had a blurred understanding of where she was and didn’t have the ability to behave appropriately.
I made a harsh complaint to the transport authority about what had transpired considering that she has a disability and should be treated accordingly.
This is the failure of people even psychiatrists to understand what schizo effective disorder looks like on a daily basis, I recently have a rotating plethora of psychiatrists allocated to my mum whose schizophrenia is so sever that if she didn’t have state guardianship she would just run off like the trolley lady and die, considering she has other major health issues as well. It took us 16 out of those 18 years to get the state to dictate where she lives and take care of her money.
Even then my mum was just put in public housing which no state official ever visited and had to turn up to her appointments where of course she says how wonderful she is going because she’s terrified of going into state care.
It has been a hard road for her and our entire family has split apart. For someone with schizophrenia, health officials can not expect the onus to be on them to make decisions. A psychiatrist that mom is seeing now keeps asking her if she wants to work. The woman has a congenital heart condition and can’t do heavy labor and can’t deal with logical thinking on a daily basis.
She also gets abuse from everyone because they don’t understand that she doesn’t know how to behave in society, she is suffering.
I would suggest that if psychiatrists really want to learn about schizophrenia that they stick to their clients on a 24 hour basis and carefully observe them and get to know them instead of leaving that up to a nurse.
The obstacles mum has in daily life are insurmountable which is why I have moved back in with her to care for her full time, many people don’t have that option or just can’t do it because it’s too hard.
Increase carers pay to $50 000 per year tax free and I think a lot of problems would be solved with schizophrenic patients, also have closer home monitoring with applicable questionnaires fro carers with checklists and with social workers and doctors.
The truth is schizophrenics have been left out in the cold and those who have had any dealings with the mental health system or a schizophrenic person know it all too well.
A mentally disabled person or person in a wheel chair will get instant help from strangers , a schizophrenic will more than likely just get abuse disdain and neglect.
There is not yet a cure for schizophrenia so society needs to start realizing that and act accordingly rather than stuffing patients on medication sending them off into the community and pretending they are o.k. when in reality until there is a cure the illness is for life medicated or not.
Well said filmtvandlife . Schizophrenia is brushed under the carpet and so is the lack of treatment options and individualised treatments. All the best for you and your mum. I hope there is. Better support quickly for you both but I sadly expect that ou have a very clear vision of a long unpredictable and arduous road ahead. You personify courage caring and committment,
I wish you the very best possible outcome.
Leah