Home » Cultural determinants and resilience and recovery factors associated with trauma among Aboriginal help-seeking clients from an Aboriginal community-controlled counselling service | BMC Psychiatry

Cultural determinants and resilience and recovery factors associated with trauma among Aboriginal help-seeking clients from an Aboriginal community-controlled counselling service | BMC Psychiatry

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Cultural determinants and resilience and recovery factors associated with trauma among Aboriginal help-seeking clients from an Aboriginal community-controlled counselling service | BMC Psychiatry

The Indigenous literature on resilience, healing and recovery from trauma has identified common factors documented in the broader trauma recovery literature (e.g., establishing safety, constructing meaning from traumatic events), in addition to cultural determinants of wellbeing (e.g., cultural identity, cultural practices) and collective processes of healing (e.g., strengthening self-determination, building community capacity, restoring cultural norms). The majority of literature is qualitative and this makes it difficult to establish the extent to which these risk and protective factors differentially contribute to trauma-related outcomes. The aims and findings of this study were part of a larger research program undertaken that examined historical loss, contemporary trauma, and resilience and recovery outcomes among Aboriginal help-seeking clients using an Aboriginal community controlled counselling service [30]. In the present study we investigated associations between several unexplored, culturally salient factors – specifically, client’s experiences of child removal from natural family, racism, and being male—and posttraumatic stress symptom severity. We also investigated the potential moderating role of resilience (i.e., client’s access to strengths and resources, including cultural strengths) and the contributions of trauma exposure, stressful life events, and resilience in predicting trauma symptom severity.

Before discussing these results, we note several broader findings with regards to the assessment of trauma exposure and trauma symptom severity. First, on average, participants reported experiencing a high number of traumatic events during their lifetime (mean = 12.73). Notably, when we compare this finding with those from studies using the original Harvard Trauma Questionnaire with marginalised cultural groups, the extent of trauma exposure in this study was comparable to that reported in studies examining refugee populations who have experienced large-scale collective trauma [39]. The elevated rates of trauma exposure in this study are consistent with large scale studies involving American Indian populations that found a risk of higher rates of trauma exposure for both men and women in two American Indian reservation communities [40]. We also noted that 40 per cent of the participants reported experiencing symptom patterns consistent with PTSD when assessed using the Aboriginal Australia Version of the Harvard Trauma Questionnaire. Further, similar to Atkinson’s findings, participants reported experiencing a broad range of symptoms of distress that included trauma and culturally salient idioms of distress [19]. This is an important finding for practitioners and services because it reinforces results from studies indicating the importance of assessing all three trauma related domains of distress when working with Aboriginal and Torres Strait Islander people.

Most participants in this study reported having experienced racial discrimination in their lives, and there was a significant association between the extent of racism experienced and posttraumatic stress symptom severity. This is consistent with survey findings that among Aboriginal and Torres Strait Islander people racism is a stressor associated with higher rates of psychological distress, substance abuse, and poorer self-assessed general health and mental health [41]. The finding is also consistent with research conducted among other minority groups that have found a relationship between experiences of racism and PTSD [42]. For example, Matheson and colleagues (2019) conducted surveys with First Nation Canadian, Metis and Inuit adults recruited from community/health centres in Canada and found that after controlling for education, posttraumatic stress symptom severity was associated with greater perceived discrimination [43].

Posttraumatic stress symptom severity among participants with a history of childhood removal did not differ to those with no such history. However, a post-hoc analysis revealed that participants who reported two generations of child removal in their families, reported experiencing more traumatic events in their lives and higher trauma symptom severity, in comparison to those who did not. This finding supports the view that multiple generations of child removal in families elevates the risk of experiencing adversity and confer a vulnerability to experiencing mental health and social and emotional wellbeing difficulties [44]. The finding that male participants reported higher trauma symptom severity in comparison to than female participants, despite experiencing no differences in levels of trauma exposure, is contrary to worldwide epidemiological data that has consistently found higher prevalence rates of PTSD and higher levels of trauma exposure among females [45]. However, with respect to gender and trauma exposure, Beals and colleagues also reported comparable levels of trauma exposure between men and women in a large study involving nearly 2000 adults from two American Indian reservation communities [40]. The finding is also congruent, with the focus group discussions that preceded this study, in which Aboriginal health staff at the counselling service observed that males appeared to be particularly vulnerable to the impact of historical trauma and the loss of land, language and identity [30]. Intergenerational trauma theories described by J. Atkinson [46] and Miller [47] proposed that the loss of traditional knowledge, roles and status for some Aboriginal males as a result of colonisation leads to poor self-image and uncertainty about the future. This, when combined with poor coping skills and elevated rates of substance use, can manifest as frustration and aggression, potentially escalating into violence and other stressful life experiences.

There was a strong, negative association between participants’ composite total strengths scores on the Aboriginal Resilience and Recovery Questionnaire [30] and trauma symptom severity, with total strengths contributing a substantive 31 per cent of the variance in trauma symptom severity. The subscales of the ARRQ include a range of personal strengths (e.g., self-worth, emotional regulation), relationship strengths (e.g., access role models, social support), community strengths (e.g., opportunities in community, communal mastery) and cultural strengths and resources (e.g., cultural identity). As such, the finding is consistent with investigations of models of resilience as a multidimensional construct that includes personal, social and environmental capacities [48, 49]. Significantly, we found that total strength scores of the AARQ moderated the relationship between trauma exposure and trauma symptom severity. Specifically, the regression model showed that the relationship between trauma exposure and trauma symptom severity was no longer significant when high levels of resilience were entered into the model. Whilst this study is cross-sectional and cannot establish a causal directionality, this moderation finding is consistent with the idea that the capacity of clients to access and draw upon strengths and resources is a factor in mitigating posttraumatic stress symptom severity.

It highlights the importance of practitioners taking a strength-based approach to therapeutic work with Aboriginal and Torres Strait Islander help-seeking clients who have experienced significant trauma. This finding contributes to the emerging evidence base documenting the moderating effects of resilience in the area of mental health and wellbeing [50, 51]. One other study finding a moderating effect of resilience specific to interpersonal trauma exposure (i.e., not combat exposure) and trauma symptom severity, was conducted by Fincham and colleagues [52]. They found that resilience moderated the relationship between childhood abuse and PTSD symptoms among 787 secondary school students from five public secondary schools in Cape Town, South Africa. Our finding is also consistent with Indigenous intergenerational trauma theories that emphasise the importance of culture, relationships and community connectedness in healing trauma [25, 28, 53, 54].

We investigated the contributing roles of resilience, trauma exposure and stressful life events together when predicting trauma symptom severity, while controlling for access to basic living expenses. It is noteworthy that all three factors, in addition to access to basic living expenses, all uniquely predicted trauma symptom severity, accounting for 60 per cent of the variance in trauma symptom severity. Within the context of supporting Aboriginal and Torres Strait Islander help-seeking clients with histories of trauma, the finding highlights the need for services to take an interdisciplinary approach that includes social work, case management and other relevant services that can help clients to address these three areas of wellbeing. That is, support clients to establish a level of financial security, mitigate the impacts of stressful life events (including exposure to interpersonal trauma, such as experiences of racism, family and community violence), and strengthen access to personal, relationship, community and cultural resources (i.e., resilience).

Several important limitations with regards to the findings need to be noted. First, the study was cross-sectional and therefore unable to determine individual post trauma trajectories and causal directions. Hence, participants reporting low trauma symptoms and high strengths could have experienced resistance (e.g., no trauma impact), resilience (e.g., early trauma impact followed by a fast return to baseline functioning) or recovery (e.g., slow return to baseline functioning) post trauma pathways. The study design also means it is not possible to determine whether the strengths outlined in the ARRQ played an antecedent role in contributing to post-trauma outcomes. It is possible that participants reporting high levels of posttraumatic stress symptom severity may currently view themselves in a more negative light and underestimate their current strengths, and/or that over time, the impact of posttraumatic stress has contributed to depleting these strength-related psychosocial and cultural resources. Another limitation of the study is that it is not clear how generalisable the findings are to other Aboriginal and Torres Strait Islander population groups. The study is limited on two fronts with regards to this issue. First, the clients recruited were a non-probability sample and not representative of the whole counselling service clinical population. For safety and ethical reasons the inclusion criteria for participation precluded those clients that were either currently suffering acute distress, or experiencing long-term severe mental health problems such that the interview could potentially exacerbate any current conditions. In addition to not being a non-probability sample, the participants from the study cannot be viewed as a ‘clinical population’ in that a proportion of participants were also former counselling clients that now used the service on an as needs basis, while others were users of the broader health service or family members of participants. The service site for this research was small, and this level of flexibility for participation was required in order to make the study feasible. Second, and more broadly, due to the paucity of current research in this area, it is difficult to compare these findings with other Aboriginal and Torres Strait Islander communities and cultural groups. The findings may have differed significantly had the research been conducted in more remote or rural Aboriginal and Torres Strait Islander communities.

Finally, a limitation of this study lies in our use of a PTSD symptom structure that is now outdated and has since undergone multiple revisions. The Australian Aboriginal Version of the Harvard Trauma Questionnaire [19] is the only current culturally adapted PTSD measure available, and it was developed using PTSD symptom criteria from the Diagnostic and Statistical Manual of Mental Disorders III-R [35]. Whilst efforts are underway to develop an Aboriginal and Torres Strait Islander designed PTSD measure that includes the most recent PTSD symptom clusters [20] these initiatives had not yet commenced at the time of this study and that research is still in progress. We also note that current evidence suggests the most recent PTSD factor structure may not represent the best symptom structure among non-Western populations [55].

These limitations notwithstanding, our findings demonstrated that a range of personal, relationship, community and cultural strengths were found to be associated with lower posttraumatic stress outcomes, and to have a greater protective effect at higher levels of trauma exposure. In addition, several historical and culturally salient factors were found to be predictors of trauma symptom severity. These findings add to the Aboriginal and Torres Strait Islander, and broader Indigenous trauma and recovery literature .

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