Best Practice
Screening & Assessment
Background
There is a pressing need for best practice, culturally appropriate assessment tools that are developed, applied and understood to support the collection of culturally relevant information obtained within a culturally secure assessment process, by culturally competent health and mental health practitioners. The National Practice Standards for the Mental Health Workforce (2013) require mental health practitioners to use culturally appropriate assessment instruments and techniques, and to consider cultural issues that may impact upon the appropriateness of assessment, care and treatment for individuals, and involve their family/carers. This requires culturally validated and culturally secure assessment tools to support effective treatment and recovery for people with mental health issues or mental disorders (Social Health Reference Group 1995 p6).
The CBPATSISP research team conducted a literature review of screening and assessment tools and measures, as well as reports on their use in research and practice with Indigenous peoples up until July 2019. The group identified tools that are currently in use, either for research and/or in practice, through a review of the literature and discussion with colleagues working in the field. These tools include structured or semi structured diagnostic interviews, survey and self-report questionnaires, measures of treatment outcome, and qualitative approaches.
A working group (comprising Indigenous psychologists including clinicians, an Indigenous psychiatrist and other content experts) have reviewed the range of screening and assessment tools and measures. This process has identified those tools and measures that support culturally sensitive and appropriate screening and assessment of social and emotional wellbeing, mental health, stress, trauma, treatment outcome and cognitive screening in Aboriginal and Torres Strait Islander people. A comprehensive summary of the screening and assessment tools is included in the relevant sections below.
Purpose
The aim of this resource is to provide practitioners working with Aboriginal and Torres Strait Islander people in a range of settings, including general medical practice, emergency services, primary, secondary and tertiary mental health services with guidance on culturally responsive screening and assessment of social and emotional wellbeing, mental health issues and distress.
This resource provides a directory of available tools that have been grouped into three categories based on our review of the literature.
- Culturally validated: development was led by or involved Aboriginal clinical or cultural experts in the study and the tool was validated for use with Aboriginal and Torres Strait Islander people
- Culturally adapted: a tool initially developed for the general population has been adapted and evaluated for use with Aboriginal and Torres Strait Islander people
- Not culturally adapted or validated screening and assessment tools used in research and practice with Aboriginal and Torres Strait Islander people.
Culturally Appropriate Practice
Mental health as holistic health
For Aboriginal people mental health is holistic, bound up in the social, emotional, spiritual and cultural life of people and communities which is conceptualised within the Aboriginal Social and Emotional Wellbeing framework. A full appreciation of this holistic notion of health and mental health is crucial as part of the contextual matrix within which assessment takes place. Practitioners are also required to comply with culturally specific principles and practices included in relevant national, state and local guidelines, policies and frameworks.
Guidance on Culturally Appropriate Use of Assessment Tools
Screening and assessment are an important, yet complex area to help address the magnitude and nature of mental health and wellbeing issues being faced by Aboriginal individuals, families and communities. The low levels of confidence among practitioners in using many existing assessment tools for Aboriginal clients means that fewer assessments are undertaken than within the wider population. There are concerns regarding under-diagnosis of Post-Traumatic Stress Disorder (PTSD) and other mental health issues (Adams, Drew & Walker, 2014 p. 286 )
Adams et al. (2014) refer to the challenges for mental health practitioners and services in “addressing the potential cultural bias and monoculturalism, lack of understanding of Aboriginal culture, pervasive transgenerational impacts of colonisation upon Aboriginal children”, p. 286) and the need for greater understanding of more holistic conceptions of mental health and SEWB among Aboriginal families and communities. This is reinforced by a recent review by Black et al. (2018) that points to the need for practitioners working with Indigenous Australians to have training in cultural competence and to consider the cultural appropriateness of diagnostic tools when applied to this population” (p. 383). These authors have also noted that “further validation of the use of diagnostic instruments in Indigenous Australians is needed so that the prevalence of psychiatric disorders in this population can be accurately determined” (p. 383).
Practitioners require increased knowledge and abilities of culturally appropriate screening and assessment tools to assess and treat Aboriginal people. Culturally competent assessment offers the promise of a shift from ‘discourses of distress’ to ‘discourses of hope’.
Guidelines & Principles of Best Practice in Screening & Assessment
Principles of practice
Adams, Drew and Walker (2014) have reviewed issues and principles of practice for mental health assessments. These include the standards and guidelines listed below, several of which have since been updated.
Australian Psychological Society Guidelines
- Australian Psychological Society (APS). (2015). Ethical guidelines for the provision of psychological services for, and the conduct of research with, Aboriginal and Torres Strait Islander peoples (members only) Ethical guidelines: Complementing the APS Code of Ethics (Thirteenth Edition), 7-14. Melbourne: Author.
- Australian Psychological Society (2018). Ethical Guidelines for psychological assessment and the use of psychological tests: Complementing the APS Code of Ethics, Melbourne: Author.
Aboriginal Indigenous Psychology Association
The Aboriginal Indigenous Psychology Association (AIPA) emphasises the need for practitioners to understand:
- The potential impact of adverse life events on serious psychological distress and SEWB;
- The factors that protect against the development of serious psychological distress following adverse life events;
- The consequences of high and prolonged levels of psychological distress on Aboriginal and Torres Strait health and mental health; and
- Detection of individuals and groups who are at high risk of mental ill health due to high and prolonged levels of psychological distress.
Royal Australian College of General Practitioners (RACGP) – National guide to a preventative health assessment for Aboriginal and Torres Strait Islander people
The third edition of the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people (National Guide) is a joint initiative of the National Aboriginal Community Controlled Health Organisation (NACCHO) and The Royal Australian College of General Practitioners (RACGP). The National Guide is a practical resource intended for all health professionals delivering primary healthcare to Aboriginal and/or Torres Strait Islander peoples. Its purpose is to provide health professionals with an accessible, user friendly guide to best practice in preventive healthcare for Aboriginal and Torres Strait Islander patients. The National Guide lists several tools for screening for social and emotional wellbeing in young people. Those relevant are discussed in the screening and assessment sections below.
Royal Australian and New Zealand College of Psychiatrists
The Royal Australian and New Zealand College of Psychiatrists (RANZCP) recognises the unique place of Aboriginal and Torres Strait Islander peoples in Australia, and acknowledges their ongoing spiritual and cultural custodianship of their lands.
The RANZCP’s Aboriginal and Torres Strait Islander Mental Health Committee is composed of psychiatrists who have direct experience working in Aboriginal and Torres Strait Islander mental health, as well as Aboriginal and Torres Strait Islander community members who are involved in mental health service provision and policy development. It is committed to and passionate about improving access to effective mental health care for Aboriginal and Torres Strait Islander peoples and/or communities.
It’s important that health professionals working in Aboriginal and Torres Strait Islander communities take a holistic approach to their work in order to achieve the best outcomes possible.
The Dance of Life, developed by Professor Helen Milroy, is a multi-dimensional model which combines paintings, narrative, theory and existing evidence into a framework designed to assist practitioners in understanding health and wellbeing from an Aboriginal perspective.
The Dance of Life framework outlines factors that can affect the mental health and social and emotional wellbeing of Aboriginal and Torres Strait Islander people. The Dance of Life matrix outlines physical, psychological, social, spiritual and cultural dimensions that health and mental health workers should consider in their assessment.
- Dance of Life – see table 16.1 in Adams, Drew & Walker (2014, p. 277-278)
Considerations when selecting and using tools
In addition to the CBPATSISP cultural principles, the following criteria have been applied in including assessment tools on the CBPATSISP website. Similar considerations need to be made by practitioners, researchers and evaluators when using these tools
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Key Considerations
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Think about the following:
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What is the purpose of using the tool?
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a) Understanding SEWB, levels of distress, suicide risk, b) Screening or assessment, c) Measuring progress over time or outcomes d) Research or evaluation
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Is the tool culturally appropriate?
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Is there evidence that: a) cultural context and issues have been considered in developing the tool?, b) Aboriginal people were involved in the development?
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Has the tool been validated for use with Aboriginal and Torres Strait Islander people?
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a) If yes, has the tool validated for specific groups (ie young people, pregnant women, LGBTIQ) and community contexts (urban, rural remote)? b) Is the tool available in Indigenous languages or in English only? c) If no, can it still be used in a reliable and valid manner? d) What evidence is available supporting the tool and its use for the purpose of my work?
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Other considerations when selecting and using tools
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Key Considerations
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Think about the following:
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Is the tool being used in a culturally safe environment?
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a) Have relationships been developed and trust established prior to using the tool? b) Will the tool be acceptable to consumers and practitioners and be completed in a meaningful manner?
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Do I have the expertise to apply the tool?
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a) Am I confident I can use the tool effectively? b) Do I need training to use the tool and to interpret results?
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Am I culturally sensitive?
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a) How will I provide feedback to an individual (and their family) who has completed the screening or assessment tool?
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