What is true about the social and emotional wellbeing of Aboriginal and Torres Strait Islanders people?

Social and emotional wellbeing is the foundation for physical and mental health for Aboriginal and Torres Strait Islander people (PM&C 2017). It is holistic, in that it results from a network of relationships between individuals, family, kin and community. Indigenous Australians’ experience of social and emotional wellbeing varies across different cultural groups as well as across individuals. The concept of social and emotional wellbeing also recognises that a person’s wellbeing is influenced by the social determinants of health, engendered through the inequity of government policies, institutional racism, the effects of colonisation and other past events. For Indigenous Australians, health is not just the physical wellbeing of the individual but the ‘social, emotional and cultural wellbeing of the whole community’, and is based on connections to country, culture, community, family, spirit and physical and mental health (Dudgeon P. et al. 2014; Gee et al. 2014; Parker & Milroy 2014; Social Health Reference Group 2004). The National Strategic Framework for Aboriginal and Torres Strait Islander Mental Health and Social and Emotional Wellbeing 2017–2023 proposes a model of social and emotional wellbeing with seven overlapping domains comprising: body; mind and emotions; family and kin; community; culture; country; and spirituality and ancestors (Gee et al. 2014; PM&C 2017).

Culture and cultural identity are critical foundations of a person’s social and emotional wellbeing and their capacity to lead successful and fulfilling lives. The social determinants of health are the conditions in which people are born, grow, live, work and age, and are mostly responsible for health inequalities (WHO 2020). The causes of inequality have been identified as unequal access to health care, schools and education, conditions of work and leisure, housing, and the associated chances of leading a healthy life (Australian Psychological Society 2018). The antecedents of which are due to the structural disadvantage brought about by social policy, economic systems and the distribution of power and resources.

Social determinants of health have a strong impact on social and emotional wellbeing. The social determinants of health, including education, employment, income and position within Australian society, have been linked with other external stressors such as serious illness, disability, inadequate housing, inaccessibility of reliable utilities, overcrowding, exposure to violence including family violence, substance misuse, incarceration, and interpersonal and institutional racism. Taken together, many of the negative impacts upon the social and emotional wellbeing of Indigenous Australians arises from their ongoing experience of entrenched disadvantage.

This experience of disadvantage is further reflected in Indigenous Australians’ experience in mainstream health care. It has been shown that traditional western models of health treatment, including failure to communicate effectively, can result in discharge against medical advice by Indigenous patients, which could be avoided with improvements to institutional cultural safety (Einsiedel et al. 2013). Peak Indigenous health bodies argue that culturally safe and culturally competent clinical care may substantially contribute to Indigenous health improvement (Laverty et al. 2017). It follows that a more specific embedding of cultural safety within mandatory standards for safe, quality-assured and culturally competent clinical care may strengthen the health system in delivering care that meets the needs of Indigenous Australians (see measure 3.08 Cultural competency).

Social and emotional wellbeing problems are distinct from mental health problems and mental illness, although they can interact and influence each other (PM&C 2017). The National Strategic Framework for Aboriginal and Torres Strait Islander Mental Health and Social and Emotional Wellbeing 2017–2023 recognises this distinction. Even with good social and emotional wellbeing, people can experience mental illness. People with mental health problems or mental illness can live and function at a high level with adequate support, and continue to have social and emotional wellbeing needs. Mental health is a positive state of wellbeing in which a person can manage their thoughts and feelings to cope with the normal stress of life and reach their potential in work and community life in the context of family, community, culture and broader society. Mental health problems are ‘diminished cognitive, emotional or social abilities but not to the extent that the criteria for a mental illness are met’, for example psychological distress. Mental Illnesses are diagnosed according to certain criteria. They range from high prevalence disorders such as anxiety and depression, through to low prevalence disorders such as psychosis, schizophrenia, and bi-polar disorder.

The COVID-19 pandemic has posed, and continues to pose, a high risk to Indigenous Australians’ physical and social and emotional wellbeing (Victorian Government et al. 2020). Specific concerns have included: lack of accessible, culturally appropriate and culturally safe mental health services; challenges faced by the Indigenous Australian allied health workforce, including those living with high-risk individuals; inequalities within the health system that may affect access to care, particularly in the move to digital and telehealth; and loss of remote community services including fly in fly out mental health care. The impact of lockdowns is particularly acute for Indigenous Australians who are deeply interconnected with family and community members, and where caring responsibilities may have been disrupted. There are heightened effects on those in, or with connections to, remote communities, where isolation has been greater and freedom of movement more restricted; those who cannot access waterways, songlines and country; and those who cannot attend to cultural and sorry business. Tailored, collaboratively built solutions are needed, with Indigenous Australians taking leadership of and being engaged in shared decision-making regarding mental health supports to ensure they are culturally competent, safe and sustainable.

In July 2020, the National Agreement on Closing the Gap (the National Agreement) identified the importance of enjoying high levels of social and emotional wellbeing. The target for this outcome is to see a significant and sustained reduction in the suicide of Aboriginal and Torres Strait Islander people towards zero. See Intentional self-harm deaths (suicide) in this measure for data on suicide. Non-fatal hospitalisations for intentional self-harm and hospitalisations for mental health-related disorders have been identified as supporting indicators for the target, and information on these is also contained in this measure. 

For the latest data on the Closing the Gap targets, see the Closing the Gap Information Repository.

The new National Aboriginal and Torres Strait Islander Health Plan 2021-2031 (the Health Plan), provides a strong overarching policy framework for Aboriginal and Torres Strait Islander health and wellbeing and is the first national health document to address the health targets and priority reforms of the National Agreement. Priority 6 of the Health Plan focuses on ‘Social and emotional wellbeing and trauma-aware, healing-informed approaches’ to service delivery. Priority 10 of the Health Plan focuses on mental health and suicide prevention.

Burden of disease

In 2018, mental and substance use disorders were the leading cause (23%) of total disease burden for Indigenous Australians, and was responsible for 42% of the non-fatal burden (46% for males and 38% for females). 

The conditions contributing the most burden include:

• anxiety disorders (23% of burden due to mental and substance use disorders)
• alcohol use disorders (19%)
• depressive disorders (19%)
• drug use disorders (9%)
• schizophrenia (7%).

After adjusting for differences in the age-structure between the 2 populations, the rate of burden due to mental and substance use disorders for Indigenous Australians was 2.8 times the rate for non-Indigenous Australians (70 and 25 DALY per 1,000 population, respectively). Mental and substance use disorders were the top contributor to the gap in disease burden between Indigenous and non-Indigenous Australians, accounting for one-fifth (20%) of the total gap (AIHW 2022).

Findings

What does the data tell us?

Findings from ABS survey data

The 2018–19 National Aboriginal and Torres Strait Islander Health Survey (Health Survey) collected information on a range of topics relevant to social and emotional wellbeing. The survey showed that Indigenous Australians retain links to their culture and family connections. In 2018–19, 66% (314,170) of Indigenous Australians aged 15 and over identified with a tribal/language group or clan and 74% (357,420) recognised an area as homelands/traditional country (Table D1.18.1).

In 2018–19, of Indigenous survey participants who were able to state whether they or a family member had been removed, 54% (214,200) reported that they and/or a relative had been removed from their natural family. Those who were removed or whose relatives were removed from their family were more likely to have high levels of psychological distress (38%; 81,165) than those who had not been removed or had a family member removed from their family (26%; 133,105) (Table D1.18.5).

In 2014–15, 63% (277,700) Indigenous Australians aged 15 and over were involved in cultural events, ceremonies or organisations in the last 12 months, 92% (406,400) could get support in a time of crisis and 97% (429,800) reported that they had been involved in sporting, social or community activities in the last 12 months (Table D1.13.3, Table D1.13.4).

The 2014–15 National Aboriginal and Torres Strait Islander Social Survey (Social Survey) included an overall life satisfaction measure with a scale from 0 ‘not at all satisfied’ to 10 ‘completely satisfied’ (ABS 2016). More than half (53%; 236,700) of Indigenous Australians aged 15 and over reported an overall life satisfaction rating of 8 or above (52% in Non-remote areas and 58% in Remote areas). A high rating of 10 was more common in Remote areas (27%; 26,200) than Non-remote areas (14%; 49,100).

A high life satisfaction rating of 8 or above for Indigenous Australians was associated with a self-assessed health status of excellent or very good (67% compared with 37% of those with fair/poor health); being employed (62% compared with 41% for those who were unemployed); not experiencing violence in the last 12 months (58% compared with 39% of those who did experience violence); and having support in a time of crisis (55% compared with 38% for those without support) (Figure 1.18.1) (ABS 2016).

Figure 1.18.1: Proportion of Indigenous Australians aged 15 and over reporting high life satisfaction ratings, by selected characteristics, 2014–15

Source: AIHW and ABS analysis of the National Aboriginal and Torres Strait Islander Social Survey 2014–15 (ABS Table 17.3).

Based on analysis of the 2008 Social Survey and the Household Income and Labour Dynamics in Australia Survey (HILDA), 53% of Indigenous Australians reported that they had ‘been a happy person’ all or most of the time in the previous four weeks, compared with 61% of non-Indigenous Australians (AIHW 2014). Higher levels of education and being employed were associated with higher levels of wellbeing (Kahneman & Deaton 2010). However, there was a weaker link between income and positive wellbeing for Indigenous Australians in Remote areas compared with Non-remote areas.

Further analysis of HILDA results in the period 2001–12 showed that life satisfaction ratings peaked in 2003 for both Indigenous and non-Indigenous Australians, but declined significantly after that point for Indigenous Australians only (Manning et al. 2016).

Psychological distress

The 2018–19 Health Survey showed that 67% of Indigenous Australians aged 18 and over had low/moderate levels of psychological distress and 31% had high/very high levels, up 4 percentage points since 2004–05 (27%). The proportion of non-Indigenous Australians reporting high/very high levels of psychological distress was 13% in both 2004–05 and 2018–19 (Table D1.18.35, Figure 1.18.2).

Figure 1.18.2: Proportion of people aged 18 years and over reporting high/very high levels of psychological distress (age-standardised), by Indigenous status, 2004–05, 2008, 2012–13, 2014–15 and 2018–19

Source: Table D1.18.35. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Health Survey 2004–05, 2008, 2014–15, 2018–19; National Health Survey 2004–05, 2007–08, 2014–15, 2017–18; Australian Aboriginal and Torres Strait Islander Health Survey 2012–13 (2012–13 NATSIHS component); Australian Health Survey 2012–13.

After adjusting for differences in the age structure between the two populations, Indigenous adults were 2.4 times as likely as non-Indigenous adults to experience high levels of psychological distress in 2018–19 (31% compared with 13%).

Indigenous females were more likely than Indigenous males to report high levels of psychological distress (35% compared with 26%). By remoteness, the proportion of Indigenous adults reporting high levels of psychological distress was 32% in Non-remote areas and 28% in Remote areas (Table D1.18.3).

In 2018–19, Indigenous adults reporting high levels of psychological distress were more likely to:

• have lower income (44% compared with 18% of those with high income),
• be unemployed (42% compared with 22% for those who were employed),
• smoke (38% compared with 27% for non-smokers),
• have a disability (46% compared with 18% for those with no disability),
• have three or more long term health conditions (42% compared with 15% for those with no long term health conditions) (Table D1.18.6, Table D1.18.7, Figure 1.18.3).

Figure 1.18.3: Proportion of Indigenous Australians aged 18 and over reporting high/very high levels of psychological distress, by selected socioeconomic and health factors, 2018–19

Source: Table D1.18.6 and D1.18.7. AIHW and ABS analysis National Aboriginal and Torres Strait Islander Health Survey 2018–19.

Life stressors

The 2014–15 Social Survey showed that 68% of Indigenous Australians aged 15 and over had experienced one or more stressors in the last 12 months. The most reported stressors for Indigenous Australians were death of a family member or close friend (28%), inability to get a job (19%), serious illness (12%) and mental illness (10%). Indigenous Australians experienced an average of two stressors in the last 12 months (Table D1.18.4, Figure 1.18.4).

Figure 1.18.4: Personal stressors experienced in the last 12 months, Indigenous Australians aged 15 and over, 2014–15

Source: Table D1.18.4. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Social Survey 2014–15.

Compared with Indigenous Australians living in Remote areas, those in Non-remote areas were more likely to report stressors due to serious illness (13% compared with 9%), mental illness (12% compared with 6%) and discrimination (5.0% compared with 3.6%). Compared with Indigenous Australians living in Non-remote areas, those living in Remote areas were more likely to report stressors such as the death of a family member or close friend (35% compared with 26%), overcrowding (9.3% compared with 5.8%) or alcohol problems (8.9% compared with 5.9%) (Table D1.18.4).

Depression and racism

The 2018–19 Health Survey showed that 25% (109,350) of Indigenous Australians aged 15 and over felt that they had been treated unfairly in the last 12 months because they were Aboriginal and/or Torres Strait Islander. Rates of high/very high psychological distress were higher for this group (45%; 48,795) than for those who reported that they had not been treated unfairly (28%; 91,890) (Table D1.18.5).

Social and emotional wellbeing of children

The 2014–15 Social Survey showed that 67% (116,500) of Indigenous children aged 4–14 were reported to have experienced one or more stressors in the last 12 months. The most commonly reported stressors were death of family/friend (25%; 43,500), being scared or upset by an argument or someone’s behaviour (23%; 40,000) and trouble keeping up with school work (23%; 39,800). In addition, 40% (68,900) of Indigenous children aged 4–14 had been bullied at school and 9% (15,300) had been treated unfairly at school because they were Aboriginal and/or Torres Strait Islander (ABS 2016).

Mental health conditions

In the 2018–19 Health Survey, 24% (187,500) of Indigenous Australians aged 18 years and over reported having a current, diagnosed long-term mental health condition (ABS 2019). The most commonly reported long-term mental health conditions for Indigenous adults were depression or feeling depressed (78%), anxiety or feeling anxious or nervous (78%), behavioural or emotional problems (30%) and harmful use of drugs or alcohol (14%) (Table D1.18.33).

Indigenous males aged 18 and over were less likely to report having a mental health condition than Indigenous females (25% compared with 34%) (Table D1.18.33). Indigenous young people aged 0–14 (15%) were less likely to report having a mental health condition than those aged 25 and over (ranging from 27% to 32%) (ABS 2019).

Two in five (39%) Indigenous Australians reported having ever been diagnosed with a mental health condition, this proportion was lower for Indigenous males (33%) than for Indigenous females (44%). Those in remote areas were less likely than those in non-remote areas to report having ever been diagnosed with a mental health condition. Of those who reported any mental health condition diagnosis, the most commonly reported conditions were depression or feeling depressed (76%), anxiety or feeling anxious (68%) and harmful use or dependence on alcohol or drugs (24%). These outcomes were relatively consistent across sex and area of remoteness (Table D1.18.43).

The 2014–15 Social Survey found that Indigenous Australians aged 15 and over with a mental health condition were more likely than those with no long-term health conditions to:

• be a daily smoker (46% compared with 39%),
• have used harmful substances in the last 12 months (39% compared with 29%),
• report experiencing one or more personal stressors in the last 12 months (84% compared with 60%),
• have experienced physical violence in the last 12 months (20% compared with 12%),
• have experienced problems accessing health services (23% compared with 10%) (ABS 2016).

Indigenous Australians aged 15 and over with a mental health condition were less likely to have had daily face-to-face contact with family or friends outside their household (36%) than those with no long-term health conditions (52%) (ABS 2016).

Mental health related deaths (not including intentional self-harm)

Over the period 2015–2019, mental health-related conditions accounted for 3.7% (or 574) of all deaths for Indigenous Australians in the five jurisdictions for which the Indigenous identification in deaths data is considered to be of adequate quality (New South Wales, Queensland, Western Australia, South Australia and the Northern Territory) (Table D1.18.13 and D1.23.1).

Of these deaths, 65% (374) were from organic and symptomatic mental disorders (injury or non-psychiatric illness affecting the brain) and 20% (112) were from mental and behavioural disorders due to psychoactive substance use (Table D1.18.13).

Indigenous females had a slightly higher death rate due to mental health-related conditions compared with Indigenous males (60 and 54 per 100,000 population respectively) (Table D1.18.12).

For Indigenous and non-Indigenous Australians, the death rate for mental health-related conditions increased with age and was highest for those aged 75 and over. Death rates were similar between Indigenous males and females across most age groups, the exception being those aged between 45 and 64. The relative difference was greatest for those aged 45–54, where the rate for Indigenous males was 3.4 times that of Indigenous females (18 and 5.2 per 100,000, respectively) (Table D1.18.12).

After adjusting for differences in the age structure between the 2 populations, Indigenous Australians died from mental health-related conditions at a slightly higher rate than non-Indigenous Australians (58 and 50 per 100,000, respectively).

Intentional self-harm deaths (suicide)

In 2015–2019, in New South Wales, Queensland, Western Australia, South Australia and the Northern Territory combined:

• there were 847 Indigenous deaths from intentional self-harm (suicide), a rate of 24 suicide deaths per 100,000 population.
• suicide accounted for approximately 5.5% of Indigenous deaths (Table D1.18.30, Table D1.23.1).
• Indigenous males accounted for nearly three quarters (73%) of suicide deaths in the Indigenous population (similar to the proportion for non-Indigenous males of 76%).
• the suicide rate for Indigenous Australians was highest for those in Western Australia (36 per 100,000), followed by the Northern Territory (29 per 100,000), Queensland (26 per 100,000), South Australia (18 per 100,00) and New South Wales (17 per 100,000).
• For Indigenous Australians in Western Australia the suicide rate was 2.2 times the rate for Indigenous Australians in New South Wales (Table D1.18.30).

After adjusting for differences in the age structure between the 2 populations, the suicide rate for Indigenous Australians was twice as high as the rate for non-Indigenous Australians.

During 2015–2019, the majority (85%; 719) of suicides by Indigenous Australians occurred in those aged under 45. This pattern was different among non-Indigenous Australians, where 49% of deaths by suicide occurred in those aged under 45 years (Table D1.18.22, Figure 1.18.5).

Figure 1.18.5: Mortality from suicide rates per 100,000, by Indigenous status, sex and age group, NSW, Qld, WA, SA and NT, 2015–2019

Source: Table D1.18.22. AIHW National Mortality Database.

Between 2006 and 2019, the age-standardised suicide rates increased significantly by 58% for Indigenous Australians. Over this period, suicide rates for non-Indigenous Australians also increased, though to a lesser extent (33% increase).

Over the decade 2010 to 2019, the suicide rate for Indigenous Australians increased by 30%, while the rate for non-Indigenous Australians increased by 24%, based on age-standardised rates. The gap in the suicide rates for the 2 populations widened by 38% over the period (Table D1.18.24, Figure 1.18.6).

Figure 1.18.6: Age-standardised mortality rates and changes in the gap due to suicide, by Indigenous status, NSW, Qld, WA, SA and NT, 2006 to 2019

Source: Table D1.18.24. AIHW National Mortality Database.

Mental health conditions managed by a general practitioner

In 2010–15, around 11% of all problems managed by general practitioners (GP) for Indigenous patients were mental health-related. Depression was the leading mental health problem managed by GPs for Indigenous and Other Australians (both 2.9% of all problems). Other Australians includes non‑Indigenous Australians and those whose Indigenous status is unknown.

After adjusting for differences in the age structure between the two populations, GPs managed mental health-related problems for Indigenous Australians at 1.2 times the rate for Other Australians (173 and 139 per 1,000 encounters respectively) (Table D1.18.21).

Hospitalisation for mental health-related conditions (not including intentional self-harm)

Between July 2015 and June 2017, there were 42,185 hospitalisations due to mental health-related conditions. After adjusting for differences in the age structure between the two populations, Indigenous Australians were hospitalised for mental health-related conditions at 1.8 times the rate for non-Indigenous Australians (32 compared with 18 per 1,000) (Table D1.18.15).

Mental health-related conditions were the principal reason for 8% of hospitalisations for Indigenous Australians (excluding dialysis). Indigenous males were hospitalised for mental health-related conditions at twice the rate of non-Indigenous males (33 and 16 per 1,000, respectively), and Indigenous females at 1.5 times the rate for non-Indigenous females (30 and 20 per 1,000, respectively) (Table D1.18.15, Table D1.02.3).

Between 2004–05 and 2016–17, there was a 76% increase in the hospitalisation rate for mental health-related conditions for Indigenous females (from 19 to 31 per 1,000), and a 55% increase for Indigenous males (from 21 to 34 per 1,000), in the six jurisdictions combined with Indigenous identification data of adequate quality (New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory) (Table D1.18.20, Figure 1.18.7).

Note: the care type Mental health was introduced from 1 July 2015. To change the care type of patients receiving mental health care, Queensland (in 2015–16) and New South Wales (in 2016–17) discharged and readmitted patients, causing the rise in hospitalisations and patient days counted in those years. Therefore, information presented for 2015–16 and 2016–17 will not be comparable with data presented for earlier periods.

Figure 1.18.7: Age-standardised hospitilisation rates from mental health-related conditions as principal diagnosis, by Indigenous status, NSW, Vic, Qld, WA, SA and NT, 2004–05 to 2016–17

Source: Table D1.18.20. AIHW analysis of National Hospital Morbidity Database.

The most common mental health-related conditions leading to hospitalisation for Indigenous Australians were psychoactive substance use (40%; 16,826), schizophrenia (23%; 9,684), mood disorders (13%; 5,526) and neurotic, stress-related disorders (12%; 5,192) (Table D1.18.17).

Hospitalisation rates for Indigenous Australians for mental-health-related issues were highest in those aged 25–54 (Figure 1.18.8). After adjusting for differences in the age structure between the two populations, Indigenous males were twice as likely to be hospitalised for mental health-related issues compared with non-Indigenous males (33 and 16 per 1,000), and Indigenous females were 1.5 times as likely as non-Indigenous females (30 and 19 per 1,000) (Table D1.18.14).

Hospitalisations from injury and poisoning and a first reported external cause of self-harm were highest for Indigenous males aged 25–34 (5.7 per 1,000) and Indigenous females aged 15–24 (8.7 per 1,000) (Table D1.18.27).

Figure 1.18.8: Age-specific hospitalisation rates for a principal diagnosis of mental health-related conditions, by Indigenous status and age group, Australia, July 2015 to June 2017

Source: Table D1.18.14. AIHW analysis of National Hospital Morbidity Database.

Hospitalisation rates for Indigenous Australians for mental-health-related conditions was lowest Inner regional areas (24 per 1,000) and highest in Remote areas (36 per 1,000) (Table D1.18.16). Rates also varied by jurisdiction; they were lowest in Tasmania (15 per 1,000) and highest in South Australia (40 per 1,000) (Table D1.18.38).

Hospitalisation for intentional self-harm

Between July 2015 and June 2017, there were 5,709 hospitalisations of Indigenous Australians due to intentional self-harm (1.1% of all hospitalisations of Indigenous Australians, excluding dialysis) (Table D1.18.28, Table D1.02.3). Hospitalisation rates for intentional self-harm were higher for Indigenous females (4.3 per 1,000) than for Indigenous males (2.8 per 1,000).

Rates of hospitalisation for intentional self-harm for Indigenous Australians varied between jurisdictions, with the lowest rates in Tasmania (1.6 per 1,000) and the highest in South Australia (5.1 per 1,000). After adjusting for differences in the age structure between the two populations, Indigenous Australians were hospitalised for intentional self-harm at 2.7 times the rate for non‑Indigenous Australians (3.7 compared with 1.4 per 1,000) (Table D1.18.28).

From 2004–05 to 2016–17, the rate of hospitalisation due to intentional self-harm increased by 120% for Indigenous females (from 2.2 to 4.5 per 1,000) and increased by 81% for Indigenous males (from 1.6 to 3.3 per 1,000). This was for the six jurisdictions with Indigenous identification data of adequate quality (New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory) (Table D1.18.29).

What do research and evaluations tell us?

Protective factors and healing

In a multivariate analysis of data from the Health and Social Surveys, conducted between 2002 and 2012–13, employment status and housing tenure were shown to be significantly associated with a range of health and wellbeing outcomes. As education levels have increased for Indigenous Australians, the association of education with health and wellbeing has weakened (Crawford & Biddle 2017).

Research into the impact of stigma and discrimination related to problematic alcohol and other drug use in Queensland found that participants ‘felt their best when connected to their families and communities, and when being noticed, respected and cared for’, and when they were able to support others (QMHC 2020). Employment and education were seen as drivers of good mental health and wellbeing.

A review of research focused on Indigenous peoples from Canada, Australia, New Zealand and the United States (CANZUS nations) found that culture is significantly and positively associated with physical health, social and emotional wellbeing, and reduces risk-taking behaviours (Bourke et al. 2018). Across the literature there were conceptual variations in defining and measuring culture. Cultural domains, including language, cultural expression and connection to country were more likely to be reported in quantitative studies, and cultural domains of knowledge, beliefs, kinship, and family were more likely to be reported using qualitative methods.

A systematic review of programs that include components to enable and support Indigenous Australians to express cultural identity found that such programs can have positive health and wellbeing effects, including on mental health and reducing substance use (MacLean et al. 2017). Research conducted with Indigenous children living on the South Coast of New South Wales found that positive emotional wellbeing was an outcome of connecting Indigenous children to cultural practices, and cultural interactions gave children a sense of identity and belonging (Crowe et al. 2017). Healthy lifestyle behaviours related to physical activity and healthy eating were interconnected with cultural practices.

A systematic review of evaluated resilience-enhancing interventions conducted in, or in partnership with, schools for Indigenous adolescents in the CANZUS nations, found that some interventions focused on fostering individual resilience only; others included aspects intended to build staff, school and/or community capacity to support adolescent resilience; and several had community/school capacity building as the primary focus (Jongen et al. 2019). Approaches based on culture were present in most studies. The evaluations described in the review found a range of positive outcomes, with the most common being in the resilience of participating adolescents, such as coping skills and communication/conflict resolution skills. Improvements in mental health related outcomes were also evident, such as reduced substance use.

Ranger programs generate employment opportunities for Indigenous Australians, and improve biodiversity and land management outcomes (Jones et al. 2018). Participation in Ranger programs facilitates cultural engagement through caring for country and transfer of customary ecological knowledge and practices. Research using data collected in Central Australia in 2017 through field testing of the Mayi Kuwayu Study compared life satisfaction, general health, psychological wellbeing and family wellbeing among 43 Indigenous Australians employed as Rangers, compared with 160 Indigenous Australians who were not employed as Rangers. The study found, after adjusting for employment, income, education, health risk factors and conditions, that Ranger participation was strongly associated with very high life satisfaction and high family wellbeing, but did not identify an association with psychological wellbeing. These findings support assertions from communities, Indigenous organisations and conservation groups that the Indigenous Ranger program is contributing towards closing gaps in health, employment and education. The study suggests that stability and expansion in policies that facilitate the development, implementation and sustainability of Ranger programs are likely to lead to improved wellbeing, health, and other gains for Indigenous Australians.

Indigenous women and girls possess social and cultural strengths which can be drawn on to drive local action as natural leaders and role-models. Dudgeon and Bray (2018) found that Indigenous Australian women’s social and emotional wellbeing has been affected by the impact of colonisation and past policies such as the forced removal of children. However, Indigenous Australian women have maintained strong leadership roles and have kept families and communities together. In recent decades Indigenous mental health and self-determination have become more prominent movements, restoring and strengthening the role women have in traditional healing practices (Dudgeon Pat & Bray 2018). Ngangkari traditional women healers are ‘leading a renaissance of cultural healing’ and are focused on a ‘restorative, holistic decolonisation of people’s social and emotional wellbeing’. The Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women’s Council employs Ngangkari healers to work in communities in the region, and in hospitals, nursing homes, hostels, health services, and prisons in regional centres (Hawthorne 2018). Traditional healing has been recognised as an important and effective intervention into the transmission of intergenerational trauma (Dudgeon Pat & Bray 2018). Traditional healers play an important role in the healing process for Indigenous Australians and influence and support the positive management of Indigenous Australians’ emotional, spiritual and physical wellbeing. ‘Building access to cultural healers and cultural healing across all parts of the Australian mental health system’ for Indigenous Australians was identified as a key element for implementing the Gayaa Dhuwi (Proud Spirit) Declaration, which proposes that change is needed across all levels of the mental health system (Dudgeon Pat et al. 2016a).

Aboriginal and Torres Strait Islander Mental Health First Aid (MHFA) Training delivered to Groote Eylandt and Bickerton Island between December 2016 and May 2017 was evaluated (NIAA 2019). Participant feedback indicated that the training was highly relevant, and 85% thought they would need to use their new skills in the next 12 months. The evaluation found the training was effective in increasing the ability of participants to recognise the signs of mental health issues, and increasing their knowledge of how to implement the MHFA action plan including how to approach, assess and assist with any mental health crisis.

Life stressors

Colonisation disrupted sources of social and emotional wellbeing within cultures, communities and families, with resulting intergenerational impacts (Calma et al. 2017). These effects are exacerbated by the negative impact of social determinants today, including the forced removal of children from families, racism and broader forms of social exclusion. Addressing these social determinants requires a collaborative approach that includes services outside the health sector, including housing, education, employment, recreation, child protection and family services, crime prevention and justice (PM&C 2017).

A demographic assessment of life outcomes facing Stolen Generations survivors and their descendants used Health and Social Survey data to identify individuals who were born before 1972 and who reported being removed from their families (AIHW 2018). Compared with other older Indigenous Australians who did not report having been removed, the Stolen Generations aged 50 years and over were found to have poorer outcomes across a range of indicators, including health status, income and employment status, home ownership, experiences of discrimination, access to services, and contact with police and the criminal justice system. The Healing Foundation designs projects that encourage collective healing, where people are supported and empowered to heal through group activities such as gatherings and family reunions (The Healing Foundation). This is particularly important for Stolen Generations survivors who were institutionalised and had connections with land and culture damaged. In addition, Link Up Services provide family tracing, reunion and support services to Stolen Generations members. Stolen Generations members can also access a range of social and emotional wellbeing services which provide practical supports such as individual counselling, case management, group therapy, community engagement, outreach, family support, group and community healing activities.

Research in the Northern Territory has found a significant association between interpersonal racism and depression among Indigenous Australians after adjusting for sociodemographic factors. Lack of control, stress, negative social connections and reactions to racism such as feeling ashamed or powerless were each identified in the relationship between racism and depression (Paradies & Cunningham 2012). A study of 755 Indigenous Australian Victorians also found an association between reported racism and psychological distress (Kelaher et al. 2014). Community consultations in Queensland outlined the profound impact that racism, discrimination and negative stereotypes had on participants’ social and emotional wellbeing (QMHC 2020).

‘Lateral violence’ affects Indigenous peoples all around the world, and stems from the sense of powerlessness that comes from oppression, where members of an oppressed group direct their fear and anger toward each other, and toward those less powerful than themselves (see measure 2.10 Community safety) (AHRC 2011). The ways in which lateral violence can affect social and emotional wellbeing are multilayered and vary based on each person’s strengths and risk factors. This effect is subtly different from other forms of bullying and violence, as it can ‘undermine cultural identity’ and ‘devalue pride in culture and self-worth’. Cultural safety and cultural security help create positive and empowered environments where the problems of lateral violence can be solved. An Adelaide study conducted interviews with 30 Indigenous Australians about their experience of lateral violence (Clark et al. 2016, 2017). The study found that many participants with high psychological distress had experienced lateral violence, but also identified strategies to handle and prevent it. Participants in the study also advocated for a broader educational campaign and healing workshops. Cultural renewal programs aim to prevent lateral violence by increasing connection to and pride in culture (AHRC 2011). Empowerment is also important because historical and continuing disempowerment breeds lateral violence. Solutions to lateral violence must come from within Indigenous communities as they exercise their right to self-determination. Governments can assist by removing the obstacles that prevent communities from taking control, and by helping build capacity within communities so they are able to take on these responsibilities.

Family violence has a profound effect on social and emotional wellbeing. Family violence, including gender-based violence, places a huge burden on Indigenous communities, especially women and children (Closing the Gap Clearinghouse 2016) (see measure 2.10 Community safety). Family violence is not part of Indigenous culture. Culture and family are key protective factors that support communities to be free of violence. Discrimination, racism and intergenerational trauma are some of the significant drivers that impact Indigenous Australians.

Breaking the cycle of violence requires community-driven, trauma informed approaches to family violence that prioritise local needs, cultural healing, family restoration and the strengths of Indigenous families. Indigenous-led solutions must support frontline and preventive services, as well as the structural drivers of violence. Programs showing promising results include the Maranguka Justice Reinvestment Project in Bourke, a model of Indigenous self-governance where an Indigenous community owned and led multi-disciplinary team works in partnership with government and non-government agencies (AIHW 2019; Just Reinvest NSW Inc.). The project is guided by the Bourke Tribal Council, comprising representatives from the different Tribal Groups living in Bourke (Just Reinvest NSW Inc. ; KPMG Australia & Just Reinvest NSW Inc. 2018). Maranguka, meaning ‘caring for others’ in Ngemba language, has delivered a number of interlinked activities designed to create impact at different levels of the community and justice system (KPMG Australia & Just Reinvest NSW Inc. 2018). Activities include the Indigenous leadership driving a grassroots movement for change among local community members; facilitating collaboration and alignment across the service system; delivering new community based programs and service hubs; and working with justice agencies to evolve their procedures and behaviours towards a proactive and reinvestment model of justice. Maranguka has successfully demonstrated reductions in police-reported family violence incidents and improvements in community safety indicators (AIHW 2019; KPMG Australia & Just Reinvest NSW Inc. 2018). In Queensland, the National Empowerment Project (NEP) Cultural, Social, and Emotional Wellbeing (CSEWB) Program was delivered between 2014 and 2016 (Mia et al. 2017). The CSEWB Program aimed to promote positive cultural, social and emotional wellbeing and mental health, build resilience and prevent psychological distress and suicide, and address community identified problems such as family violence and substance misuse that were contributing to high levels of suicide and family and community issues in two communities. The CSEWB Program was Indigenous-led, needs-based and strengthened by involving local communities and local community co-researchers in consultation, design, implementation and evaluation of the program. Considerable work was undertaken prior to program implementation to ensure community readiness and ownership. An evaluation of the CSEWB Program collected information from program participants through interviews, ‘Stories of Most Significant Change’ and a review of NEP site reports. Several female participants said the program provided them with skills to more successfully deal with family and domestic violence and family breakdown, and commit to a stronger resolve to address these issues and make better life choices for themselves, their children, and families. Interviews with participants described how the CSEWB Program had significantly changed their lives and their families’ lives in various constructive and affirming ways to bring about positive outcomes. The evaluation highlighted the need for more services and programs which address the social determinants influencing social and emotional wellbeing in Indigenous communities.

Social and emotional wellbeing of children and young people

In the Longitudinal Study of Indigenous Children (LSIC), primary carers were asked whether the child participating in LSIC had been bullied or treated unfairly at preschool or school by children or adults because they are Indigenous. Research using the LSIC found that racial discrimination places Indigenous children at a moderately increased risk of negative mental and physical health outcomes, and that age of first exposure did not have a consistently greater impact across outcomes (Cave et al. 2019). However, a stronger adverse effect was found on behavioural issues for first exposure at 7 years relative to 4–5 years, and on mental health for first exposure at 4–5 years relative to 7 years. A separate analysis found that Indigenous children participating in the LSIC who had been exposed to racism had an increased risk of emotional and behavioural difficulties (Macedo DM et al. 2019a). Another research project using the LSIC found that more than 43% of Indigenous children aged 6–10 years had six or more risk factors for mental illness in adulthood, and 23% were experiencing current psychological distress (Twizeyemariya et al. 2017). The study found that substantial risk was present from infancy, with 67% of Indigenous children aged 0–1 years exposed to three or more major life events. However despite high levels of adversity, the children participating in the LSIC generally reported a positive sense of self, suggestive of resilience. Other research has shown that Indigenous children in LSIC who experienced more major life events had a higher risk of experiencing social and emotional difficulties, and that good mental health of the primary carer was a protective buffer for children experiencing major life events (FaHCSIA 2015; Salmon et al. 2018). Macedo et al. (2019) found that ‘ethnic-racial identity’ affirmation had a protective effect on Indigenous children in the LSIC who had been exposed to racism, while children with low ethnic-racial identity affirmation, whose parents reported they experienced discrimination/racism, were at increased risk of poor social and emotional wellbeing two years later (Macedo Davi M et al. 2019b).

Research has shown that parental stress caused by factors such as unemployment and financial problems is associated with emotional or behavioural difficulties in children and decreased utilisation of health services for the child's needs (Ou et al. 2010; Strazdins et al. 2010).

The Study of Environment on Aboriginal Resilience and Child Health (SEARCH) is a large-scale cohort study in New South Wales, which aims to identify the determinants and trajectories of health in urban Indigenous children and their caregivers, conducted in partnership with four Aboriginal Community Controlled Health Services. Phase one was conducted over the period 2006 to 2012, involving 1600 Indigenous children and their caregivers, and phase two (which is a follow up of phase one) is not yet released. Research drawn from Phase one studied findings of 119 Indigenous teenagers living in urban areas, using a Strengths and Difficulties Questionnaire to measure resilience (Young et al. 2019). The study found that most Indigenous adolescent participants displayed resilience, while 16% were at high risk of clinically significant behavioural and emotional problems. Greater resilience was associated with nurturing family environments, social support and regular exercise.

A 2013 review of research, policies and programs addressing the social and emotional wellbeing of Indigenous youth found that there is a need for greater recognition of the extreme circumstances many Indigenous youth grow up within, and that successful ways forward require strengths-based holistic approaches that promote cultural identity (Haswell et al. 2013).

A 2013 evaluation of a Brisbane headspace social and emotional wellbeing group-based program examined two-month follow up data available for 49 Indigenous youth participants aged 11–21 years (Skerrett et al. 2018). The evaluation found a decrease in suicidal ideation and indications that participants improved their understanding of holistic health and had an increased number of coping skills.

The save-a-mate (SAM) Our Way program was evaluated in 2012, and was operating in 14 sites across the Northern Territory, Queensland, South Australia, and Western Australia at the time (Blignault et al. 2016). The program’s broad aim was to improve the social and emotional wellbeing of young Indigenous Australians, with a focus on depression, anxiety, violence and alcohol and other drug problems, by engaging young people and strengthening stakeholder and community responses to wellbeing issues affecting Indigenous youth. The program took a community development approach based on culturally respectful ways of working and partnerships with Indigenous communities. The evaluation found a tension between community development and specific program delivery, and that program staff at each site learned not to be too ambitious, and to work consistently with the community to establish partnerships, gain trust and engage and train community members.

Intentional self-harm and suicide

A study of emergency department presentations at the Alice Springs Hospital and Royal Darwin Hospital in the Northern Territory reviewed 167 presentations involving suicide-related thoughts and behaviours over a two month period in 2013 (Leckning et al. 2020). Indigenous patients were more likely than non-Indigenous patients to present from Remote areas and to report substance misuse and family conflict or violence. In both groups, males were more likely than females to be admitted, and people presenting with self-harm were more likely to be admitted than those who had suicidal thoughts only. The study did not identify any differences in discharge arrangements by Indigenous status. Exposure to family conflict or violence is strongly indicative of the effects of intergenerational trauma on community and family functioning that increases the likelihood of psychological distress. Family and community are also an important source of identity and social and emotional wellbeing, protective factors against suicide-related thoughts and behaviours. An understanding of family relationships can assist with ‘appropriate assessment of individual and contextual risk and sources of cultural strengths and resilience’ to help ensure decisions about aftercare for Indigenous patients lead to appropriate and safe support.

High Indigenous suicide rates arise from a complex web of interacting personal and social circumstances (Dudgeon Pat et al. 2017). A history of colonisation, burden of intergenerational trauma, and contemporary disadvantage and discrimination can impact on potential sources of social and emotional wellbeing and resilience that help protect Indigenous people against suicide. Indigenous Australians’ greater exposure to life stressors, traumatic events, passing away of family members and friends, attendance at grieving rituals and associated drug and alcohol use are also factors. Cultural education, cultural reclamation activities and cultural continuity have a significant role to play in Indigenous suicide prevention, particularly for young people.

A systematic review found that Indigenous youth in Australia have elevated rates of suicide, self-harm and suicidal ideation (Dickson et al. 2019). Risk factors included being incarcerated, substance use and greater social and emotional distress. The review found there was a scarcity of information on predictors of suicide and self-harm (Dickson et al. 2019). High rates of non-fatal intentional injury are an important focus for preventive and early intervention (Azzopardi et al. 2017).

National Coronial Information System data have shown that over 2007–2015 Indigenous children aged 4-17 years accounted for 19% of all child deaths due to suicide (AHRC 2019).

An audit of reported suicide deaths provided to the Kimberley Mental Health and Drug Service for the period 2005–2014 found that Indigenous suicide rates in the Kimberley region had dramatically increased over the decade, with an overall trend upwards in youth suicides and female suicides (Campbell et al. 2016). A study in Western Australia found that Indigenous mothers were 3.5 times as likely to commit suicide as non-Indigenous mothers (Fairthorne et al. 2016).

A coronial inquest into 13 deaths of children and young people in the Kimberley that occurred from 2012 to 2016 found that 12 occurred by way of suicide (Fogliani 2019). The coroner found that individual events were shaped by the effects of intergenerational trauma and poverty upon entire communities. The coroner’s report made 42 recommendations including improved screening and services for people with fetal alcohol spectrum disorder; restrictions on take away alcohol; the appointment of a Commissioner for Indigenous children and youth; and that emphasis be given to principles of self-determination and empowerment in policies and programs relating to Indigenous Australians in Western Australia, with measures introduced to facilitate their involvement. The report acknowledged the considerable services being provided to the region, but concluded that they were insufficient and provided by mainstream services that were attempting to adapt in culturally relevant ways. The coroner recommended consideration of services being co-designed, with ‘a more collective and inclusive approach towards cultural healing’. The 2016 Message Stick Inquiry found that Indigenous youth suicide is indicative of a distressed community and that effective solutions must be community focused (Education and Health Standing Committee 2016). The Government of Western Australia’s response to the coroner’s inquest and the Message Stick report was released in March 2020 (Government of Western Australia 2020).

The Coroners Court of Victoria (2020) released a report on suicides of Indigenous Australians in Victoria, prepared by the Coroners Koori Engagement Unit and Coroners Prevention Unit (Coroners Court of Victoria 2020). The report found that between 1 January 2009 and 30 April 2020, there were 117 suicides of Indigenous Australians in Victoria. Of these 82 were male and 35 were female. Over half (59.8%) of the suicides occurred in Regional Victoria, with 40.2% occurring in Metropolitan areas of Victoria. Indigenous Australian Victorians had experienced higher rates of contact with the legal system (Police, Courts and Corrections) within six weeks and within 12 months prior to suicide, compared with all Victorians. Substance use and misuse was identified as a contextual stressor in 82.6% of suicides of Indigenous Australian Victorians, and experience of abuse (either as the perpetrator or the victim) in 63.8% of suicides. Interpersonal stressors were identified in around two-fifths of suicides of Indigenous Australian Victorians, described as conflict with partner (44.9%), conflict with family members (43.5%), family violence with partner, either as the perpetrator or the victim (36.2%) and separation from partner (47.8%). The report notes that due to the low frequency of suicides, the data must be interpreted with caution.

Implications

The policy responses to social and emotional wellbeing need to be multidimensional and involve a wide range of stakeholders. It is paramount that strategies build on the strengths, resilience and endurance within Indigenous communities and recognise the important historical and cultural diversity within communities (Dudgeon P. et al. 2014; Social Health Reference Group 2004). Suicide prevention studies have identified the need to focus on protective factors, such as community connectedness, strengthening the individual and rebuilding family, as well as culturally based programs (AIHW & AIFS 2013; Clifford et al. 2012; Cox et al. 2014; Dudgeon P. et al. 2012; Ridani et al. 2015; Tighe & McKay 2012). Approaches to suicide prevention should be Indigenous-led, and include healing activities and support to address community challenges, including the use of community support people. The increasing Indigenous suicide rate suggests that current approaches to Indigenous suicide prevention are not yet effective (Dudgeon Pat et al. 2017). To support access to mental health services for Indigenous Australians it is important for all mental health services to offer a culturally safe environment (see measure 3.10 Access to mental health services). Culturally valid understandings must shape the provision of services and guide assessment, care and management of Indigenous Australians’ health (Department of Health 2017). Mental health services staff working with Indigenous Australians at risk of suicide and in Indigenous communities should demonstrate cultural competence and provide trauma informed care (Dudgeon P et al. 2016b). Guidelines have been developed for best practice assessment of Indigenous Australians presenting with self-harm or suicidal thoughts at hospitals (Leckning et al. 2019).

Addressing the needs of Indigenous Australian youth in particular, requires investment and actions in sectors that extend beyond health (Azzopardi et al. 2020). For example, the education sector provides an important platform for building Indigenous youth wellbeing and resilience, and opportunities for early intervention and prevention, and it is important that education is culturally safe and responsive to the needs arising from socioeconomic inequity, insecure housing, teenage parenthood and poor physical and mental health.

The Indigenous Advancement Strategy’s (IAS) Safety and Wellbeing Programme provides funding to a range of social and emotional wellbeing services and workforce support, Aboriginal and Torres Strait Islander Mental Health First Aid and the National Indigenous Postvention Service, to enhance community safety and support Indigenous wellbeing.

The National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2017–2023 provides a dedicated focus on Aboriginal and Torres Strait Islander social and emotional wellbeing and mental health and sets out a comprehensive and culturally appropriate stepped care model that is applicable to both Indigenous specific and mainstream health services. The Framework is designed to complement the Fifth National Mental Health and Suicide Prevention Plan (the Fifth Plan), endorsed in 2017. The Fifth Plan seeks to establish a national approach for collaborative government effort from 2017–2022 across eight targeted priority areas, including improving Indigenous Australian mental health and suicide prevention. More information on the Framework, Fifth Plan and the Implementation Plan for the Fifth Plan is in <Policies and Strategies>.

The National Agreement on Closing the Gap was developed in partnership between Australian governments and the Coalition of Aboriginal and Torres Strait Islander Peak Organisations. The Agreement has recognised the importance of Indigenous Australians enjoying high levels of social and emotional wellbeing by establishing the following outcome and target to direct policy attention and monitor progress:

• Outcome 14 – Aboriginal and Torres Strait Islander people enjoy high levels of social and emotional wellbeing.
  • Target – Significant and sustained reduction in suicide of Aboriginal and Torres Strait Islander people towards zero.

The National Agreement has also recognised that strong Aboriginal and Torres Strait Islander cultures are fundamental to improved life outcomes for Indigenous Australians and that all activities to be implemented under the Agreement need to support, promote and not diminish these cultures. In particular, the Agreement has established the following outcomes to support the cultural wellbeing of Indigenous Australians:

• Outcome 15 – Aboriginal and Torres Strait Islander people maintain a distinctive cultural, spiritual, physical and economic relationship with their land and waters.
  • Target – By 2030, a 15 per cent increase in Australia’s landmass subject to Aboriginal and Torres Strait Islander people’s legal rights or interests.
  • Target – By 2030, a 15 per cent increase in areas covered by Aboriginal and Torres Strait Islander people’s legal rights or interests in the sea.
• Outcome 16 – Aboriginal and Torres Strait Islander cultures and languages are strong, supported and flourishing.
  • Target – By 2031, there is a sustained increase in number and strength of Aboriginal and Torres Strait Islander languages being spoken.

Priority 6 of the Health Plan focuses on ‘Social and emotional wellbeing and trauma-aware, healing-informed approaches’ to service delivery, and includes the following objectives:

• Objective 6.1 Update and implement a strategic approach for social and emotional wellbeing
• Objective 6.2 Support Aboriginal Community Controlled Health Services to deliver social and emotional wellbeing services
• Objective 6.3 Support Aboriginal and Torres Strait Islander organisations to provide leadership on healing and social and emotional wellbeing
• Objective 6.4 Implement training and other support across the whole health system to better understand and respond to social and emotional wellbeing in all aspects of life.

Priority 10 of the Health Plan focuses on mental health and suicide prevention. A number of objectives focus on strengthening culturally safe suicide prevention services, improving continuity of care, and implementing key reforms to Indigenous mental health and suicide prevention policy.

The policy context is at Policies and strategies.

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Related measures