Treatment and Rehabilitation

Abstract

This chapter focuses on treatment and rehabilitation programs for Aboriginal people—that is, programs and services designed to facilitate recovery from harmful alcohol use and/or dependence and to prevent relapse into harmful drinking. We trace the emergence from the 1970s of a distinctive approach based on residential treatment and combining a disease concept of alcoholism with the Twelve Steps pathway developed by Alcoholics Anonymous. This approach has remained widely used to the present day. We also discuss the growth of a variant of the disease model, in which alcohol misuse, together with associated harms such as violence, sexual abuse and self-harm, are viewed as products of unresolved intergenerational trauma associated with colonisation, requiring cultural reconnection and a healing process grounded in Indigenous rather than (or as well as) Western therapeutic approaches. The chapter also reviews initiatives in non-residential treatment, support for the Aboriginal alcohol and other drug workforce, and issues relating to the evaluation of treatment.

4.1 Introduction

This chapter focuses on tertiary prevention—that is, on programs designed to facilitate recovery from harmful use and/or alcohol dependence and prevent relapse to harmful drinking. As we noted in the preceding chapter, measures to prevent and treat harmful alcohol use among Aboriginal Australians have tended to take the form of primary prevention initiatives, such as education and media campaigns, or tertiary prevention, also known as treatment and rehabilitation programs (Brady et al. 1998: 47; Brady 1995a). In this chapter, we focus on treatment and rehabilitation. We begin by tracing the evolution of what has been, from the outset, the most widely favoured treatment approach among Aboriginal people: residential treatment using the Twelve Step treatment path to overcome alcoholism, combined with the mutual aid principles of Alcoholics Anonymous (AA), both of which are based on the concept of alcoholism as a disease. We then discuss a variant of the disease model, in which alcohol misuse is regarded as a ‘family disease’. A third section examines a related but distinct treatment approach that views alcohol misuse, together with associated harms such as violence, sexual abuse and self-harm, as products of unresolved intergenerational trauma that in turn requires a process of healing and cultural reconnection. This is followed by sections dealing with non-residential treatment programs, support for the Aboriginal alcohol and other drug workforce and, finally, issues relating to evaluation and the demonstration of treatment effectiveness.

4.2 Twelve-Step-Based Residential Treatment

The first alcohol treatment program established for and by Aboriginal people in Australia, as mentioned above in Chap. 2, was Benelong’s Haven, a residential facility set up in Sydney in 1974 by Val Bryant, an Aboriginal woman of Gumbaynggirr descent. In 1976, with her husband Jim Carroll, Val moved the facility to the site of a former boys’ home at Kinchela Creek, 35 kms from the town of Kempsey (Chenhall 2007).

Three inter-related components made up the approach to treatment at Benelong’s Haven. The first, as mentioned earlier in Chap. 2 (Sect. 2.3.1) was the belief that alcoholism was a disease; the inability to cease or control one’s drinking, according to this belief, resulted not from moral weakness (as earlier approaches to drunkenness in many societies assumed) but from the onset of a disease requiring treatment. The second component was the twelve-step pathway first enunciated by the founders of AA in the US in the 1930s and retained by AA in substantially the same form until the present day.¹ The third component was the principle of self-help through mutual support as developed by AA and practised in AA meetings.

All of these components have been subject to criticism, as we discuss below. But from the earliest days of Benelong’s Haven, they have provided Aboriginal treatment services with an enduring rationale for program development.

As we noted earlier in Chap. 2 (see Box 2.2 above), Aboriginal alcoholism in the eyes of Val Bryant differed from its counterpart in non-Aboriginal society by virtue of two characteristics of Aboriginal society and culture: its group orientation (in contrast to non-Aboriginal individualism) and its spirituality. Both were central to the model of recovery, practised at Benelong’s Haven, and both were facilitated by the AA approach, despite its non-Aboriginal origins.

The most detailed account of any Aboriginal residential treatment program in Australia is Richard Chenhall’s ethnographic study of Benelong’s Haven, based on fieldwork conducted over nearly two years in the late 1990s (Chenhall 2007). Chenhall noted that concepts such as ‘disease’ and ‘treatment’ took on distinctive meanings at Benelong’s Haven:

Although it does stress that alcoholism is a disease and not indicative of ‘weak will’, the AA program, set out in the Big Book, focuses on the subjective experience of the alcoholic rather than on any objective identification of alcoholism itself. Alcoholics are not ‘treated’ but ‘work’ a spiritual program, which is reinforced by the collectivity. Thus, AA is based on the idea that alcoholics can provide their own treatment. By regularly meeting together and engaging in the AA program, individuals become part of a group of like-minded people (Chenhall 2007: 142).

Culture, spirituality and political self-determination were all interwoven in the recovery program:

For residents of Benelong’s Haven, alcohol and drugs were viewed as having removed the Aboriginal spirit, leaving them a fractured and divisive people. With the forging of a shared identity through the formation of common goals and purpose, residents asserted that they were rediscovering their Aboriginal spirituality. AA teachings support a discourse where alcohol and drugs become a poison that render the user powerless and threatens loss of life or mind. Rather than engaging in the lies and excuses that are said to be the common practice of individuals who engage in substance misuse, relationships in Benelong’s Haven are based on a concept of self-exposure and moral truth. The formation of group solidarity within the centre is seen as the main avenue through which residents can alter their relationship with the world. One resident expressed this when he stated: ‘We gotta take the spirit out of the bottle and put it back between us’. Of course the readjustment of residents’ relationship with the world is the aim of many other rehabilitation centres. However in Benelong’s Haven this was politicised so that residents’ efforts to regain what has been lost took on a historical perspective that was viewed as part of a larger Aboriginal movement of self-determination (Chenhall 2007: 225-26).

In the years that followed its establishment, Benelong’s Haven became a model for other Aboriginal residential treatment programs, including Moree Aboriginal Sobriety House (MASH) in NSW, the Foundation of Rehabilitation for Aborigines with Alcohol-Related Difficulties (FORWAARD) in Darwin, Wandering in Western Australia, Namatjira Haven in Lismore, and a centre on Palm Island, Qld. (Brady 2002). Aboriginal Sobriety Groups, also based on AA, were also created in Adelaide (Sumner 1984) and Melbourne (Commonwealth of Australia House of Representatives Standing Committee on Aboriginal Affairs 1977).

One of the earliest residential treatment programs was established in Broome, in the Kimberley region of Western Australia, where a local group known as the Broome Aboriginal Alcohol Committee was formed in 1978 to generate community support and resources for an alcohol rehabilitation centre. The Committee’s efforts are described in an account published in the Aboriginal and Islander Health Worker Journal in 1985:

The Broome Aboriginal Alcohol Committee became known as Milliya Rumurra, meaning First Day, or Brand New Day, in July 1978, when their two alcohol counsellors returned from training in Perth. The committee was made up of a chairman and vice-chairman, a secretary/treasurer and six other members. The committee asked various members of the Broome community to give their services on an advisory committee. This meant that Milliya Rumurra had a lot of contacts and support with many different parts of the community. On the advisory committee were magistrates, the police superintendent, the assistant shire clerk, the prison superintendent, a shire councillor, a doctor from community health, a social worker, a local businessman, a teacher and an accountant. All kinds of expertise were available to Milliya Rumurra.

The group sent information to the National Aboriginal Conference, who wrote to the Minister for Aboriginal Affairs in support of their work. The Broome Shire Council formally gave support to the group and offered them the use of the Civic Centre for educational films at only a small charge (Daniele 1985: 30).

The group was granted a site through the Aboriginal Lands Trust for a rehabilitation centre. Initially, counsellors worked without a regular income and used their own cars. Despite the extensive local support, it was not until January 1980 that Milliya Rumurra received ongoing government funding for its program (Daniele 1985).

By 1986, Milliya Rumurra had expanded both its funding base and range of activities. Clients attending the residential program stayed for a minimum of three months, sometimes alone, sometimes with their families (Read 1986). According to one staff member’s account, clients on arrival were ‘physically, mentally and spiritually sick’, requiring one-to-one counselling to identify their challenges and potential solutions (Read 1986: 38). The program had six main components, itemised in Box 4.1.

Box 4.1 Milliya Rumurra’s Treatment Program in 1986

Extract from Read (1986: 39–40).

The permanent parts of the program are: (1) AA; (2) Medical talks; (3) Nutrition talks; (4) Financial budgeting; (5) Arts and crafts; (6) Women's programs.

• 1. AA

  We at Milliya Rumurra promote a total sobriety program. Clients meet twice a week for meetings to help them understand their ways when drinking and how to work for sobriety.

• 2. Medical talks

  Most of our clients are aged 30+ and have little understanding of how their bodies work and even less understanding of what alcohol and drugs do to their bodies. By the use of films, slides, charts and discussion, people gain knowledge of the effects of alcohol on the body. These talks extend into associated areas such as high blood pressure, diabetes, STD, and fetal alcohol syndrome.

• 3. Nutrition talks

  Alcohol dependents come into treatment poorly nourished, as all money goes for grog and very little for food. On discharge most clients will only be receiving unemployment benefits or pensions, so it is important to teach people how to purchase and prepare cheap nutritious food. Whilst at the centre we try and keep carbohydrates to the minimum, especially encouraging people to cut down on sugar intake. We encourage people by taking them bush or to the coast to use more traditional foods, bush tucker, fish, turtle.

• 4. Financial budgeting

  If previously all money has gone for grog, it is important to teach again how to budget money for rent, food, clothing and other things. All clients are encouraged to start up savings accounts and to save money from each cheque.

• 5. Arts and crafts

  Time passes for alcohol addicted people in buying alcohol, drinking it, or sleeping it off. When alcohol is no longer there they need activities to fill their time. We run many different courses but especially encourage the more traditional crafts such as carving.

• 6. Women’s groups

  We believe that, although women could attend all other groups, there is a need for their own, away from the men. Again these groups are flexible, discussing issues such as parenting skills, child care, contraception, STD, breast self-examination and women's health, assertion skills for women, and goal setting. Women also have an opportunity to discuss problems related to their drinking.

In order to assess the effectiveness of programs at the centre we rely mainly on verbal feedback and client assessment—if a client is showing overall improvement, that would indicate effectiveness of the program.

By the mid-1980s, Milliya Rumurra’s staff had also become increasingly concerned with the need for prevention and education as well as treatment. In attempting to meet these needs, program staff discovered that most existing resources were designed for non-Aboriginal people with good literacy. So they set about developing their own resources. In collaboration with local schools, educational materials were incorporated into curricula for Years 9 and 10 at high schools and Year 6 at the primary school. Aboriginal student health workers also received training in physical and mental aspects of substance abuse and in prevention and counselling skills (Read 1986).

In later years, Milliya Rumurra underwent further changes. The most important of these was a shift away from relying on the disease concept of alcoholism to a harm-minimisation approach that incorporated controlled, moderate drinking as a treatment option alongside abstinence (Strempel et al. 2004: 44). Also, in 1998, Milliya Rumurra tendered successfully to manage a newly established sobering-up shelter in Broome (Strempel et al. 2004: 47). In 2004, the Milliya Rumurra Alcohol and Drug Rehabilitation Centre was selected by the National Drug Research Institute as an example of best practice in residential treatment that could be used as a model by other communities (Strempel et al. 2004). The Centre’s program had four objectives:

• to promote safe drinking practices;

• to stop injuries and other harm caused by the misuse of alcohol;

• to strengthen family relationships and social environments; and

• to raise the health and quality of life of people who abuse alcohol and their families (Strempel et al. 2004: 44).

In order to be accepted for the residential program, clients had to have substance misuse as their primary presenting problem and to be willing to undergo detoxification at the local hospital if necessary. The program as it operated at the time is described in Box 4.2 below.

Box 4.2 Milliya Rumurra Rehabilitation Program in 2003

From Strempel et al (2004: 44–46).

Program outline

To achieve program objectives, clients have to commit themselves to a structured three-month residential program. Clients and their immediate families can be accommodated at the centre, which has a capacity of 25 people. On arrival they are individually assessed by one of the three counsellors who works through their substance misuse histories with them, and how their issues will be addressed by the weekly program. On Mondays and Fridays clients voluntarily attend anger management sessions run by the Department of Justice. On Tuesdays and Thursdays clients participate in a health education program which outlines the health and social harms of alcohol and other substances, and a social learning program which encourages clients to address issues such as assertion. These are conducted in classroom-type situations and accompanied by videos, information sheets and teacher guides. Recreational activities are scheduled for Wednesdays, and the centre has a number of vehicles (buses and four wheel drives) for transporting people on hunting and bush outings, and a dinghy for fishing trips.

Childcare is available to parents attending education and counselling sessions. As well as these structured sessions, clients and their families have access to one-on-one counselling on request and other support to help them re-establish their lives outside the centre. Many people have chronic health problems associated with their drinking, and centre staff assist with the identification and treatment of medical, dental and mental health problems while clients remain at Milliya Rumurra.

Staffing

Seventeen permanent staff and other casual staff are employed to manage and run the rehabilitation program. These include the manager/coordinator, counsellors, other program staff, bookkeepers, receptionist, gardeners, cook, childcare workers and nightwatchman. Twelve of the 17 permanent staff members are Indigenous. Although the centre aims to employ as many Indigenous staff as it can, the demanding nature of the work and the remote location of Broome make it hard to attract and retain qualified people.

…

Evaluation

Evaluation of the rehabilitation program’s success is not easy. Currently the main measure the centre judges this on is the number of completions of the three-month program. As the coordinator says, completion for many clients is a considerable achievement:

There’s a misconception about rehabilitation — that clients walk in with a whole lot of problems and walk out with all the problems solved. We try to get people to accept that a lot of work needs to be done by them. Some people have been drinking 20 to 30 years; it’s unrealistic to turn this around in three months. One client has been here seven times and is currently abstinent. Lots of clients say that there’s so much content in the program, they don’t get it the first time — especially those people with literacy and numeracy problems.

Of the 93 clients who commenced the three-month residential program in 2001–02, 25 (27%) completed 9–12 weeks, a further 17 (18%) completed 13–16 weeks, and three (3%) remained for 17–20 weeks. Before leaving Milliya Rumurra, all clients should have a Discharge Summary Plan, which outlines support for them in the community and any follow-up offered, or planned, between counsellors and clients.

At the time of the above report no resources were available for following up with clients to see whether or not they had ceased drinking and/or reduced levels of alcohol-related harm. However, an AA meeting was held on Tuesday mornings at Milliya Rumurra’s sobering-up shelter, followed by a session of their Health Education Program. This enabled ex-clients and others to maintain links with Milliya Rumurra staff (Strempel et al. 2004: 46).

In 2014, the National Indigenous Drug and Alcohol Committee (NIDAC) singled out Milliya Rumurra as an example of an effective treatment program that combined evidence-based mainstream approaches to alcohol and other drug problems with culturally specific interventions (National Indigenous Drug and Alcohol Committee (NIDAC) 2014).

4.3 Alcoholism as a Family Disease

All of the residential treatment programs mentioned above, whatever the differences among them, shared a common focus on the individual drinker as the subject of treatment and rehabilitation. In the view of several people with ‘front line’ involvement in addressing Aboriginal alcohol issues, this was too narrow a scope. Harold Hunt, a one-time alcoholism counsellor with the Health Commission of NSW and Chairman of the National Aboriginal Campaign against Alcohol and Drug Abuse, argued that alcoholism was a ‘family disease’ requiring interventions involving the whole family (Hunt 1981: 3). He called for three levels of intervention, focusing on:

• (a) Alcoholism as it affects the individual alcoholic;

• (b) Alcoholism as it affects the alcoholic's family;

• (c) Alcohol abuse as it affects the community (Hunt 1977: 25).

In an article published in 1981 in the Medical Journal of Australia, Hunt argued that interventions into alcoholism, which he described as a ‘family disease’, needed to be embedded in a broader policy framework that addressed conditions giving rise to alcohol misuse. An extract from the article is reproduced below.

Box 4.3 What Can Be Done?

Extract from Hunt (1981: 2–3).

Alcoholism in Aboriginal communities needs to be tackled on two fronts—one front related to health programmes and the other to tackling the broader social issues which confront Aborigines today. In the short term, we have to keep Aborigines alive.

Health Programmes

AA, Al-Anon. AI-Ateen ²

In treating alcoholism, we need to be aware of all the options available. However, I believe that alcoholism is a family disease–whole families are affected and, hence, whole families need treatment. There is a total treatment available to the alcoholic and his or her family, and it has been around for a long time. Possibly someone you know is a living proof of its effectiveness. I refer, of course, to the treatment programmes which consist of Al-Ateen for children, Al-Anon for spouses and close family members, and Alcoholics Anonymous (AA) for the drinker. This family-treatment programme for alcoholism has proved to be a most effective method, usually succeeding when all other methods of treatment have been tried and found ineffective.

…

Treatment for alcoholism must be intensive in the early stages, and then be continued on a regular basis. If a diabetic is taking insulin irregularly or stops it altogether, he or she becomes sick—so, too, will those suffering from alcoholism if their treatment is stopped or given only occasionally.

…

I believe that AA, Al-Anon and AI-Ateen programmes are particularly relevant for Aboriginal people, as Aboriginal culture and lifestyle are identical to the AA philosophy. These programmes, like Aboriginal lifestyle, are based on communal spirituality.

Counsellors

Crucial to the success of the programme is the proper selection of alcoholism counsellors. Too often it has been assumed that it is most important to choose Aboriginal alcoholism counsellors for Aboriginal people. Yet, Aboriginal self-help organizations, such as the Aboriginal Medical and Legal Services, do not operate on this principle and recognize that skill is the crucial element in success; for example, they employ appropriately skilled people (doctors and lawyers) regardless of their race. The same applies to the various disciplines within the New South Wales Health Commission.

Until this rule is applied to counselling Aboriginal sufferers from alcoholism, success will be minimal. It follows that we should select staff with the most appropriate skills and provide them with an adequate training programme. Of course, we would prefer Aborigines with these skills, where possible.

Detoxification Units

There is a need for detoxification units to be established in many more hospitals throughout the State. Hospitals that need particularly urgent attention are those in Walgett, Bourke, Brewarrina, Wil­cannia, Goodooga and Lake Cargellico, because of their large number of Aboriginal inpatients.

Health Education

Changing society's attitudes to drinking is a long-overdue health education activity.

Broader Issues Which Need Tackling

While the above strategies would deal with the health issues of alcoholism, there are a number of other issues which, strictly speaking, lie outside the health field, but which, nonetheless, have a significant effect on the prevalence of alcoholism amongst my people.

Unemployment

Aborigines have the highest level of unemployment of any group in our society today. It is normally easier to count the number who are employed rather than those who are unemployed. The provision of employment opportunities will significantly improve the well-being of my people.

The Welfare Society

Over the last 200 years, a welfare society has been created for Aboriginal people, which has destroyed incentive and created a state of apathy. This has been done by depriving our people of basic resources (such as hunting lands, our sources of traditional food and materials for shelter) and self-respect (by ignoring our religious beliefs, laws, languages and our views on possible ways of coexisting together). In their place, flour and blankets were handed out in the past, while today it is “cold cash” doled out by a host of competing and confusing welfare agencies, with no real dialogue taking place between the giver and the receiver. Further, in too many cases we are seen as a separate species, “the Aboriginals”, rather than as Australian citizens of Aboriginal descent with the same rights and responsibilities as all other Australian citizens.

This situation can be corrected only by giving appropriate support (not necessarily financial) to people who are making personal efforts to improve their lot to their own satisfaction, rather than to the satisfaction of people unfamiliar with the realities of the situation.

Rights and Justice

The deprivation of hunting rights and of the rights to gather building materials (for example, timber, grass, brush), as a result of the takeover of our land without consultation with Aboriginal people, has been a denial of the people's rights and entitlement to justice.

This situation is not entirely reversible. However, the powers that be should at least consult with Aboriginal people and be guided by us in whatever action is necessary to deal with the present and to plan for the future. The past is where it belongs, so let us not be blinded by resentment and hence neglect to gain by the lessons learned from history.

In retrospect, Hunt’s analysis is notable for several reasons. Firstly, like many Aboriginal people concerned with alcohol problems, he viewed the AA ‘philosophy’ as being congenial to Aboriginal culture, largely because of the emphasis both perspectives place on what Hunt called ‘communal spirituality’. Secondly, he insisted that counsellors working in Aboriginal alcohol programs must be properly trained and skilled, and that level of skill was more important than being an Aboriginal recovering alcoholic. Thirdly, he argued that alcohol-focused interventions needed to be complemented by programs and policies that addressed contributing conditions such as high unemployment. Finally, he drew attention to the corrosive effects of the welfare system on Aboriginal society—an argument that Noel Pearson would later develop in labelling what he called ‘passive welfare’ as a key factor in contributing to alcohol and other drug misuse.³

A shift in focus from individual drinkers to drinkers’ families found practical expression in the 1980s in several programs in the Northern Territory. In 1985, Roger Sigston, an alcohol counsellor working in remote Aboriginal communities, published a paper in the Aboriginal and Islander Health Worker Journal in which he argued that the family—defined somewhat vaguely as ‘close and/or important kin’—must be the focus of intervention for two reasons: firstly, in contrast to other social entities such as Aboriginal communities and community councils, families had the potential capacity to bring about change in the drinking behaviour of members (provided they were given appropriate support); secondly, families had also become unwitting facilitators of alcohol misuse as a result of drinkers appropriating resources intended for the wider kin network to fund their alcoholic lifestyles. Change in drinkers’ behaviour would, therefore, require change at a family level (Sigston 1985).

At around the same time—between 1983 and 1985—the Darwin-based Catholic Missions established what was initially called the Alcohol Awareness Sobriety Centre, offering a treatment approach based on a ‘family disease’ model of chemical dependency (d’Abbs 1990: 21). The concept of chemical dependency originated in the US in the 1940s, where it became known informally as the Minnesota Model. The model retained the concept of alcoholism as a progressive disease that could be arrested but not cured, but broadened it to other addictive substances (Cook 1988). Like alcoholism, chemical dependency also had a spiritual dimension. The concept of chemical dependency as a family disease involved the recognition that dependency affected all members of the family as well as the drinker, exposing all of them to a risk of becoming emotionally, spiritually and physically sick (Cook 1988; d’Abbs 1990). In developing a residential treatment program for Aboriginal people in the NT, Catholic Missions also drew ideas from the Holyoake Institute, a Perth-based alcohol rehabilitation facility established in 1975, and Kakawis, a family residential alcohol treatment program in Vancouver, Canada.

In 1987, the Sobriety Centre—now renamed Alcohol Awareness and Family Recovery (AAFR)—opened a residential treatment program for families at Wulk Witby, 200 km southwest of Darwin and close to the Aboriginal community of Daly River (today known as Nauiyu). The program took the form of an intensive four-week course, with separate courses for drinkers—categorised as ‘dependent’—and the spouses or partners of drinkers, who were categorised as ‘codependents’. (A ‘codependent’ according to this perspective is someone—often a spouse of a dependent drinker—who is seen as meeting psychological needs of their own by facilitating the self-destructive behaviour of the dependent person, for example, by shielding them from the full consequences of their actions.) Sustainable change in the behaviour of the dependent, according to this model, also requires a change in that of associated codependents. (For accounts of the development and application of the concept of codependency, including critiques, see (Anderson 1994; Gordon and Barrett 1993; Haaken 1990; Gomberg 1989).

In an independent evaluation of the program conducted in 1990, the drinking status of 82 former clients of the Daly River Family Program was compared with that of a random sample of 79 residents of the same community who had not attended the program (d’Abbs 1990). Former clients were found to be more likely to be non- drinkers, and less likely to be heavy drinkers, than those who had not attended the program, although the differences were not statistically significant.

4.4 Criticisms of the Disease Concept and Twelve Step Programs

As we noted earlier in Chap. 2, the notion that habitual alcohol misuse is best conceptualised as the disease of ‘alcoholism’ has long been contentious. On the one hand, there is no doubt that some problem drinkers become physiologically dependent on alcohol to a degree that they are no longer capable of regulating their intake. Labelling this condition a disease, at the very least, indicates that the drinker’s inability to regulate or stop drinking is not simply a product of moral weakness. On the other hand, not all those whose drinking harms themselves and/or others fall into this category. Many Aboriginal drinkers, for example, who engage in binge drinking when the circumstances allow, also demonstrate a capacity to cease drinking completely for long periods, often as a result of moving away from towns. Similarly, on occasions when the supply of alcohol to Aboriginal drinkers has been abruptly cut off, as has happened on occasions in some remote communities with local outlets, the streets and clinics have not been inundated with drinkers suffering from acute withdrawal symptoms, as the disease model sometimes leads people to expect.⁴ Habitual drinkers may be very annoyed, but most do not lapse into delirium tremens or other symptoms of physiological distress. Finally, some Aboriginal people with long drinking careers stop consuming alcohol without going through any treatment program, as Brady has shown (Brady 1993, 1995c).

The disease concept of alcoholism and the associated Twelve Step programs have also been criticised for offering too few treatment options. Since alcoholism is a disease characterised by a lack of self-control over consumption, only one strategy is considered viable: abstinence. Critics argue that this is both impractical—insofar as for some drinkers at least the social and cultural settings make cessation almost unachievable—and unnecessary, in that some people who are currently drinking at harmful levels may, with appropriate guidance and support, be able to moderate their intake without having to cease drinking altogether (Brady 1995a; Institute of Medicine 1990).

In part for these reasons, the enthusiasm of Aboriginal and other service providers for the disease model of addiction and Twelve Step programs has not been shared by the government agencies that normally fund them. As early as 1980, an internal Department of Aboriginal Affairs (DAA) review expressed scepticism about the effectiveness of programs being funded (Brady 2002). Another internal DAA review conducted in 1986 concluded that, in addition to weak evidence of treatment effectiveness, facilities were not provided with adequate support to fulfil whatever potential effectiveness they might have had, especially in regard to governance and staff training (Wilson 1986). The review called for a shift in policy away from residential rehabilitation towards prevention and community-based programs, including counselling, assessment and referral, as well as support for local AA groups. At the same time, recognising the continuing need for residential rehabilitation, the review recommended funding a smaller number of quality programs and supporting these with adequate staff training (Wilson 1986).

In 1995, responsibility for funding Aboriginal alcohol and other drug programs was transferred to the newly-formed Office of Aboriginal and Torres Strait Islander Health (OATSIH) in the Commonwealth Department of Health and Aged Care. In 2001, OATSIH commissioned Maggie Brady to review options for the improvement of residential treatment programs for Aboriginal people.

Brady noted that Aboriginal people with alcohol and other drug problems were more likely to seek residential treatment than non-Aboriginal people with similar problems, and that residential treatment facilities continued to absorb a large proportion of Commonwealth, State and Territory funds spent on Aboriginal and Torres Strait Islander alcohol and other drug services. She also identified several ongoing issues that compromised treatment outcomes. These included, firstly, continuing isolation from other services, a feature that Brady attributed to the fact that, when the first Aboriginal treatment programs were established in the 1970s, they had been able to secure their own funding stream through the Department of Aboriginal Affairs (DAA). As a result, they were independent of both Aboriginal community-controlled medical services that evolved around the same time, and from mainstream alcohol and other drug services. In general, according to Brady, once residential treatment programs had become established, they tended to receive ongoing funding, regardless of evidence of effectiveness, with a result that the structural isolation had endured (Brady 2002). One consequence was that people associated with Aboriginal treatment programs tended not to have networks linking them to a broader world of alcohol and other drug treatment. This contributed to a second issue identified by Brady: the narrow range of treatment options offered by most—though not all—residential programs. The majority were based on the Twelve Step disease model of treatment or the Minnesota Model, and promoted abstinence as the only viable treatment goal. The implied criticism, voiced by others besides Brady (e.g. (Alati 1996; Gray et al. 2000)) was directed not so much at Twelve Step programs themselves but at the absence of alternative treatment options for clients who might benefit from them.

A third issue identified by Brady was the generally low level of training in alcohol and other drug treatment among program staff, many of whose primary qualification was that they themselves were Aboriginal ex-drinkers. This was particularly problematic in light of a fourth issue identified by Brady: an increase in the numbers of people presenting for problems arising from drugs other than (or as well as) alcohol—especially opiates, amphetamines and cannabis—or polydrug use. Alcohol, though still the most common presenting drug issue, was declining in relative importance, but few treatment staff were equipped to address the emerging problems.

Finally, Brady drew attention to continuing problems with the governance of residential programs. Members of boards tended to have limited knowledge of alcohol and other drug treatment; some boards consisted entirely of members of one family group, and many board members had limited understanding of the functional differences between boards and managers (Brady 2002).

Brady recommended a number of measures to address these issues and contribute to more effective treatment programs. These are summarised in Box 4.4.

Box 4.4 Elements of a Successful Indigenous Residential Treatment Program

Extract from Brady (2002: 21–22).

So what are the essential elements of a successful Indigenous residential treatment program? Based on this research, and the advice of others (Ernst and Young Consulting Team 1996; Hunter et al. 1998; Sputore et al. 1998), the following is a guide.

Governance

• a good administrative and management base

• participation in regular quality improvement reviews by accredited reviewers

• a clear definition of the purpose of the program, either as a structured treatment program or a dry recuperative facility

• clear distinctions between the roles and responsibilities of boards and managers

• board members with knowledge and experience of mainstream residential programs

• participation by board members in training (both governance and AOD)

• rules to cover day release activities for clients, as well as rules of conduct within the program

• having the support of the local community or local population.

Training and networking

• counsellors who have training to increase their confidence and efficacy and to acquire new skills

• ongoing in-service training, staff exchanges and placements with larger organisations

• staff mentored by outside professionals

• close involvement with a local doctor to provide assessment before, during and after admission, supervision of detoxification, pharmacotherapy, assistance with care plans, advice to clients

• formal and informal partnerships with local public health professionals and State AOD services

• membership of, and participation in, relevant regional AOD NGO networks and TC associations.

Program content

• a safe drug/alcohol-free environment

• an environment that takes into account people’s cultural, familial and social circumstances in an informed and respectful manner

• time and place for clients to withdraw from a high-risk lifestyle or situation

• peer support and encouragement to withdraw from use

• education regarding strategies for maintaining moderate drinking, or a lifestyle free of drugs and alcohol, to match client’s needs

• encouragement of open reflection and discussion of personal issues related to use

• healthy lifestyle, structured activity, and balanced diet during residence

• assistance with a range of issues associated with community living and daily living skills

• providing vocational, recreational and ‘cultural’ activities

• providing practical skills through TAFE and other vocational training (literacy, carpentry, agriculture, permaculture, art production, etc.)

• planning for discharge, provision of after care and home visits after treatment, or referrals to achieve this.

4.5 Culture, Healing and Alcohol Misuse

Another approach to treating alcohol and other drug misuse among Aboriginal people focuses on the presence of unresolved, intergenerational trauma resulting from colonisation and dispossession, and the need for healing programs grounded in Aboriginal cultures. The origins of this approach were described in Chap. 2 (Sect. 1.7). As explained there, most programs based on this approach incorporate the AA-Twelve Steps treatment model but combine this with Aboriginal and other First Nations healing pathways. Many programs also incorporate one or more ‘Western’ therapies. The underlying rationale for this approach is (1) the belief that conventional Western therapies are not equipped (at least on their own) to address the traumas generated by colonisation, and (2) a belief that Indigenous cultural traditions and identity do have healing powers and procedures that are better able to meet these needs.

One of the earliest instances in Australia of an alcohol treatment program based on overseas First Nations healing practices was a residential treatment facility established by the Central Australian Aboriginal Alcohol Program Unit (CAAAPU) in Alice Springs in 1992. The CAAAPU program evolved from extensive mobilisation and consultation in Central Australia, beginning in early 1989, when several Aboriginal people in Alice Springs set up a self-help group called ‘Triple A’—or Aboriginal Alcoholics Anonymous—based on AA principles (Wynter 1991). Later in the same year, the Aboriginal Issues Unit of the Royal Commission into Aboriginal Deaths in Custody convened a ‘grog forum’ in Alice Springs, where Aboriginal participants called for a comprehensive alcohol strategy to cover the whole of the central Australian region (Lyon et al. 1992). This led to two more grog forums, at the second of which—a two-day meeting held in November 1990 and attended by more than 50 representatives of more than a dozen Aboriginal organisations—it was agreed to seek Commonwealth funding for a planning unit, which envisaged spending 12 months consulting with Aboriginal communities and organisations throughout the region and preparing a regional alcohol strategy (Lyon et al. 1992).

In the event, funding was provided for only six months, but consultation and preparation of a strategy went ahead. In its deliberations, the Central Australian Aboriginal Alcohol Planning Unit, as it was then called, drew on three main sources for ideas: a series of bush meetings held in remote Aboriginal communities; a commissioned review of alcohol interventions conducted by researcher/consultant Pamela Lyon,⁵ and a team of Canadian Indian consultants from the Nechi Institute in Edmonton, Canada, and an associated treatment facility known as Poundmakers’ Lodge (Miller and Rowse 1995). The resulting strategy was published in January 1992 as a three year, region-wide ‘Grog Action Plan’ (GAP) encompassing prevention, early intervention and treatment (Lyon et al. 1992). In anticipation of a change in role from planning to overall co-ordination of the GAP, CAAAPU itself changed its name from Central Australian Aboriginal Alcohol Planning Unit to Central Australian Aboriginal Alcohol Programs Unit (Miller and Rowse 1995). Central to the GAP was a residential treatment and training facility, to be tailored to the needs of local Aboriginal communities but “based on the model used at the Indian-run Poundmaker’s Lodge in Alberta, Canada” (Lyon et al. 1992: 39).

The proposed treatment facility was just one of several program components that would be administered by CAAAPU. As it turned out, CAAAPU did not succeed in attracting the resources that such a broad role entailed and, through the three year period covered by the GAP, became increasingly focused on establishing and running the treatment centre. Under the GAP, a research team from the Menzies School of Health Research was invited to evaluate the implementation and outcomes of the treatment program (Miller and Rowse 1995: 1). In their evaluation, the researchers grappled with several issues that have relevance beyond the specific program under review. Two, in particular, warrant consideration here. The first is: how does one adjudge success or failure in an Aboriginal residential treatment program such as CAAAPU? The second: what lessons should we take from what was, in effect, a treatment program created from three cultural components: Canadian Indian healing practices, Aboriginal cultural traditions and the principles and practices of Alcoholics Anonymous?

In evaluating treatment outcomes, the researchers—like most evaluators in comparable situations—had to make do with less than ideal, and less than complete, data. The principal data sources were records of 412 admissions from 1 October 1992 to 10 November 1994, and interviews with 97 program participants conducted between November 1993 and July 1994, including 25 who were ex-clients at the time of interview. Of the 25, only seven told the researchers they were sober, and one of these had been in jail ever since discharge.⁶

The evaluators’ interpretation of these findings is summarised in the extract below.

Box 4.5 Interpreting Outcomes of Residential Treatment

Extract from Miller and Rowse (1995: 17–18).

It is debatable whether these figures attest to success or failure. Of one thing we are sure: to count sober people is too crude a measure of CAAAPU’s success. We therefore offer three additional kinds of data to answer the question of ‘effectiveness’: (a) factors associated with length of stay; (b) ability to recall program content; and (c) orientation to aftercare.

Residential treatment is not something that Aboriginal people from central Australia take to easily. There has always been a high rate of drop-out from treatment, almost one half of all admissions staying less than two weeks. There is a slight but persistent association between dropping out early and being a person from Alice Springs, especially from a town camp or a creek-bed camp. There is a slight but persistent association between residing far (more than 150 kms) from Alice Springs and staying longer in the program. English as a first language is associated with a tendency to stay longer in the program. In short, if we take length of stay in the program as one measure of CAAAPU’s success, then CAAAPU is working better for Aboriginal people who have more in common culturally with non-Aborigines: speaking English and living in a town house.

What orientation is being given to people by the program? CAAAPU’s Treatment Policies and Procedures Manual states that ‘the residential phase of the CAAAPU program is designed to provide only a foundation of knowledge, skills, and self-awareness on which the individual must build a lifelong program of continuing sobriety and recovery.’ Our interviews with clients almost always impressed on us that clients were stimulated by the program. Their attention was actively engaged with new and interesting information; they were not bored (though some would have liked better recreation facilities). In our follow-up interviews, we asked if people had understood the lectures. Over half (13 out of 25) admitted that they had had some difficulty, but 24 of them assured us that they had learned some important things. When we asked them to recall something which they had learned, four were unable to say anything. Only 12 could give us something specific: six mentioned the effects of alcohol on the body, four referred to CAAAPU's theories of illness/denial, and two referred to other matters.

The Treatment Policies and Procedures Manual also states CAAAPU's belief that ‘the single most effective source of support for this ongoing process of self-help and recovery is the fellowship of Alcoholics Anonymous; thus, the AA philosophy and twelve steps of recovery are an integral part of the CAAAPU treatment program’. We are not sure whether clients are leaving the program with this orientation. Certainly, clients interviewed early in treatment or in the middle of their stay do not spontaneously voice an inclination to tum to AA after treatment. We asked them ‘What is the hardest thing about giving up?’ and ‘What do you think it will be like when you get home?’ These questions gave people an opportunity to mention any factors which they thought would affect their continuing recovery. Only one in ten (11%) mentioned ‘aftercare’ of any kind. More than three times that many mentioned ‘moving’ (to another city, to an outstation) as a promising possibility, and just under half spoke of the persistence of social pressures to drink. When we followed clients up, nine of the 22 interviewees who were not in gaol said that they had had no contact with aftercare agencies of any kind. Eleven mentioned having some contact with CAAAPU, but our definition of contact was loose enough to include occasional encounters in the street in which the merest pleasantries were exchanged. Among those eleven were two whose contact took the form of readmission to the residential treatment program and two who have been employed at CAAAPU since discharge. We have formed the impression that most of CAAAPU's clients do not leave the treatment program with a desire to establish themselves within an AA-style aftercare regime. They are more inclined to be considering factors such as where and with whom to live and whether they can get employment.

CAAAPU’s treatment program drew on three sources: Australian Aboriginal cultural concepts and practices, Canadian Indian healing traditions as these had been adapted by the Nechi Institute and Poundmaker’s Lodge, and Alcoholics Anonymous—a self-help movement that had been started by two non-Indigenous men in the US in the 1930s. The belief that these three strands would be mutually compatible and could be woven into an effective and acceptable treatment program rested on a number of premises: one was the shared history of colonisation, dispossession and cultural oppression common to Aboriginal Australians and Canadian Indians, a history that had also resulted in parallels in the ways in which alcohol was used and alcohol-related difficulties experienced in both populations. Another was the Nechi Institute’s apparent success in blending Indigenous healing practices with non-Indigenous therapeutic practices to create a treatment program that was culturally acceptable to Canadian Indians. A third was the already established acceptability of AA, the associated disease concept of alcoholism and the 12-step treatment pathway, among both Australian Aboriginal and Canadian Indian alcohol treatment agencies.

In practice, difficulties emerged, so much so that, in June 1994, CAAAPU terminated its relationship with Eric Shirt and Associates, the Canadian Indian consultants who had been engaged to help establish CAAAPU (Miller and Rowse 1995: 19). Miller and Rowse identified several sources of tension. One was the complex relationship between alcoholism and Aboriginal culture, as they note in the extract below.

Box 4.6 AA and Aboriginal Culture

Extract from Miller and Rowse (1995: 23–24).

CAAAPU's treatment philosophy, as we have pointed out, states that ‘the AA philosophy and twelve steps of recovery are an integral part of the CAAAPU treatment program.’ It has been essential to AA's work all over the world that clients learn to distance themselves from those aspects of their culture which have propped up their drinking. From the client's point of view, the AA group is a new (sub)culture which empowers the client to continue this critical review and, where necessary, repudiation of the culture which has supported his/her drinking. CAAAPU's commitment to AA is therefore crucial to its critical assessment of ‘Aboriginal culture’.

…

By adopting the ‘disease’ notion and by fostering Alcoholics Anonymous as a form of aftercare, CAAAPU approaches Aboriginal traditions in ways both respectful and critically innovative. CAAAPU aims to confront the pathological while supporting the spiritually fortifying elements of Aboriginal culture.

It would be possible to argue that the ‘disease’ notion, the techniques of AA and the associated suspicion of the culture of the drinker as ‘denial’ are all North American impositions on local Aboriginal leaders. We do not share this view because we have witnessed the conviction with which the Aboriginal leadership of CAAAPU has tackled the task of sifting the good from the bad in ‘Aboriginal culture’. This is a task they have performed in their own lives, struggling to be sober Aboriginal people in a cultural setting which has, in their view, long given too much ground to the culture of alcohol. There is an affinity between the North American view of what is required in the recovery from alcoholism and the challenges which have been faced by these sober Aboriginal people. This affinity was, for two and a half years, the basis of a powerful attraction between CAAAPU and Eric Shirt and Associates, giving rise to a mutually beneficial working relationship at CAAAPU.

However, we have also noted that among Aboriginal people associated with CAAAPU there have been different views about what features of Aboriginal culture should be respected and sustained and what features should be confronted.

Miller and Rowse identify three issues around which controversies arose: one was the use of mixed gender group counselling sessions. In both AA tradition and that of the Canadian Indians as practised by Poundmakers’ Lodge, men and women were expected to attend mixed counselling sessions, in part so that each could gain an understanding of the other’s experience of harmful drinking. This did not accord, however, with local Aboriginal cultural practices and disturbed some participants. A second issue was the use of English for program purposes. For many participants, English was not their first language, and many reported difficulties in following lectures and counselling sessions, particularly given the use of technical terms such as ‘dysfunctional families’. Thirdly, some participants in CAAAPU’s training programs found the training styles of ‘the Canadians’ (which, as Miller and Rowse point out, included one Māori) to be too confrontational (Miller and Rowse 1995: 24–28). Today, CAAAPU continues to offer residential treatment, as well as outreach and daycare programs, on its five-hectare property on the outskirts of Alice Springs.⁷

Another attempt to integrate the treatment approach developed at the Nechi Institute with Australian Aboriginal cultural traditions, as well as AA principles, is Gregory Phillips’ ethnographic study of alcohol, marijuana and gambling in a Cape York, Qld., Aboriginal community to which he gave the fictitious name of Big River (Phillips 2003). Phillips, an Aboriginal researcher, set out to understand the factors that shaped ongoing addictive behaviours in Big River, and why so many alcohol and other drug programs for Aboriginal and Torres Strait Islander people appeared to have little impact. He also expressed a wish to advance ‘an Indigenous point of view’ as an alternative to the analyses and explanations of non-Indigenous researchers (Phillips 2003: 2).

Phillips concluded that addictive behaviours and the violence and other harms associated with them were products of accumulated, unresolved trauma, the origins of which lay in the settler violence and displacement accompanying European colonisation, which was followed by several decades of strict missionary control, during which culturally valued ways of dealing with trauma, such as ceremonies, were suppressed. The introduction of ‘drinking rights’ in the 1960s created new, illusory opportunities for dealing with the unresolved trauma, as Bama (the name by which Aboriginal residents of the area refer to themselves) began directing their resentment and anger at each other.

‘Western’ models of sickness and health, Phillips argues, are incapable of addressing unresolved, intergenerational trauma of this kind (at least on their own) because they are grounded in a mind-body dualism that does not recognise a spiritual domain. This domain, he argues, is central to understanding unresolved trauma. It was for this reason that Phillips turned to the treatment programs developed by the Nechi Institute.

In developing his thesis, Phillips explores the relationship between ‘spirituality’ and ‘culture’ and the part that both concepts might play in addressing addictions. The term ‘spirituality’ itself, he concluded, was problematic in that it tended to have two connotations in the community: for some, it evoked Christianity, which in itself had a complex cultural legacy, with some Bama believing that a Christian God could help them overcome addictions while others associated Christianity with the missionaries’ suppression of their own culture. For others, ‘spirituality’ meant ‘dhumboon’ or traditional sorcery, which also had its positive and negative aspects. Phillips concluded that notions of spirituality, healing and ‘story places’ were inter-connected, but most readily conceptualised as ‘culture’ rather than as spirituality. He also found that, while people’s understandings of these phenomena were steeped in wisdom, many hesitated to invoke that wisdom, as if their confidence was still damaged by decades of mission-led denigration of traditional cultural practices and views—even though the era of mission control had long passed.

Like the founders of CAAAPU, Phillips believed that a program of healing based on re-invigorated Aboriginal healing practices, AA principles and the treatment program developed by the Nechi Institute in Canada offered an optimal foundation for overcoming alcohol and other drug dependence in a community. ‘Culture and spirituality’, he argued, should form ‘the foundation, not totality, of health, addictions and well-being interventions’ (Phillips 2003: 167), which would also include efforts to revive Indigenous healing practices and ceremonies; redefining community norms about acceptable and unacceptable behaviour; providing alcohol and other drug training to local people in local language; establishing a treatment centre/healing place, and educating non-Aboriginal health professionals about the nature of addictive behaviours in the community (Phillips 2003: 167–8).

Phillips’ critique of ‘Western models’ of health and sickness raises two key questions that should be flagged, even though we cannot pretend to answer them adequately here. The first concerns the so-called ‘biomedical model’ that is said to pervade Western approaches to health and medicine. While it is true, as Phillips claims, that ‘Western’ clinical medicine has been built over several centuries on a philosophical foundation that portrays human beings in terms of a ‘mind-body dualism’, this model does not adequately represent contemporary ‘Western’ approaches to health and well-being. On the contrary, as long ago as 1947 the World Health Organization defined health as “a state of complete social, mental and physical well-being and not merely the absence of disease or infirmity”.⁸ The WHO definition also includes ‘spirit’ alongside ‘body’ and ‘mind’ in its conceptualisation of a human being (Mehta 2011). The 1947 definition was in turn incorporated into the Alma-Ata Declaration on Primary Health Care agreed to at an international conference held in 1978 (World Health Organization 1978). As Brady notes, the Alma-Ata Declaration and the approach to health underlying it were particularly influential among Australian health practitioners who, in the 1970s, established the first Aboriginal community controlled health services. They also underpinned the training of the first Aboriginal Health Workers (Brady 2004: 27–41).

Similarly, the ‘biopsychosocial model’ arose in the 1980s out of a critique of mind-body dualism, broadening the scope of medical and psychiatric intervention to include social, psychological and behavioural dimensions of illness and well-being (Ghaemi 2009; Engel 1978; Wade and Halligan 2017). To view Aboriginal healing practices as an alternative to Western biomedical medicine risks portraying a caricature rather than the reality of Western health care, one that may overlook potentially helpful ‘Western’ practices.

A second question concerns the healing capacities of traditional cultures. Brady, in an article published in 1995, sounded a note of caution, pointing out that in some parts of Australia, traditional healers had expressly indicated that their repertoires of healing practices did not equip them to address today’s alcohol and other drug problems because such problems were unknown in traditional society (Brady 1995b).

More recently, Brady (pers comm.) has proposed distinguishing between two uses of ‘culture’ in relation to Aboriginal alcohol and other drug interventions in order to bring greater clarity to an inherently complex and imprecise concept. One—which she labels ‘cultural affiliation or involvement’—refers to the role of cultural connectedness and cultural identity in strengthening people’s capacity to deal with difficulties in daily life, including experiences of racism and use of alcohol and other drugs. ‘Culture’ in this sense can promote resilience, which in turn may reduce a propensity to resort to destructive forms of substance misuse. It is a basis for both primary and secondary prevention, rather than tertiary prevention or treatment. Brady also points out, however—as did the treatment providers at CAAAPU discussed above—that Aboriginal culture is not always antithetical to drinking; on the contrary, in some settings, Aboriginal culture had become, at least in part, a drinking culture.

The second use of ‘culture’ distinguished by Brady refers specifically to the use of healing practices grounded in Aboriginal cultural traditions to bring about recovery from damaging alcohol and/or other drug use and the many other problems that usually accompany entrenched substance misuse. She proposes the term ‘cultural healing’ for this usage which, unlike cultural affiliation of the first kind, constitutes a form of treatment or tertiary intervention.

One example of a ‘cultural healing’ program that has continued to evolve over the three decades since it commenced as a small self-help group is the We-Al Li healing program developed by Judy Atkinson and her colleagues in the Queensland city of Rockhampton in the early 1990s and briefly discussed earlier in Chap. 2 (Sect. 2.7). As we also indicated in Chap. 2, the We-Al Li program drew on another Aboriginal concept: Dadirri or ‘inner deep listening and quite still awareness’ (Ungunmerr Bauman 1988). In a description of the program published in 2014, Atkinson et al. explained that, like several other programs operating at the level of Aboriginal communities, and in light of the substantial resource requirements entailed in bringing about change at a community level, the We-Al Li program had moved to a ‘train the trainer’ model which Atkinson et al. described as ‘a whole of community model of education as healing’ or ‘educaring’. The model is described in the extract below.

Box 4.7 Education as Healing (The Educaring Model)

Extract from Atkinson et al. (2014: 298–99)

Educaring is a trauma-specific blend of Aboriginal traditional healing activities and western therapeutic processes. It uses experiential learning to enable participants to explore their understanding of the long-term consequences of trauma across generations and cultural tools for healing. It promotes and ensures relationships of mutual respect within the learning environment. Learning is through dialogue. Trauma-informed practice works to build cultural safety and spiritual integrity through individuals working together in the group. This requires the worker-educator to be culturally competent. It focuses on enhancing deep listening skills, self and other awareness, self and group reflective discussion and practice. Educaring is designed to heal the person while building on professional skills by focusing on transformational learning and social justice as fundamental to healing practice. It enhances levels of empowerment and self-confidence to support leadership potential (Atkinson 2006).

Educaring provides skills for working with individuals and groups using the healing power of story, cultural and personal narratives, emotional release and emotional regulation, in family history reconstruction, story maps, loss history graphs, trauma healing grams, using art, music, dance, theatre, in ceremonial processes, with children, young people, adults and Elders.

It is place-based. The stories of place can be both stories of trauma and stories of strength and resilience-healing. Place-based learning is community focused as it works to build sustainability while it skills local people to deliver local services. Aboriginal approaches to education place a strong emphasis on enhancing self and community learning. It is the process of becoming aware of self and others which underpins purposeful personal development and healing as a cornerstone to education, training and skill enhancement and professional practice.

The Educaring model, Atkinson et al. note, is designed both to heal personal trauma and to build a professional Aboriginal workforce skilled in addressing trauma-related issues in communities. The authors argue that addressing traumatic experiences as a therapeutic strategy is more likely to lead to sustainable change than therapeutic models that focus on psychosocial functioning or issues (Dudgeon et al. 2014: 299).

As mentioned earlier in Chap. 2, the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from Their Families—better known as the Stolen Generations Inquiry—led to increased Government support for healing programs. In 2009, a year after the Government issued a formal apology to the Stolen Generations, the Government provided funding for the establishment of an Aboriginal and Torres Strait Islander Healing Foundation (Caruana 2010).

In 2017, the Healing Foundation published a review of Indigenous healing programs in Canada, the US, New Zealand and Australia (McKendrick et al. 2017). The reviewers noted that in all these countries, healing programs were intended to ameliorate a wide range of problems, including violence, poor self-esteem, suicide prevention, as well as substance misuse. While all the programs reviewed employed Indigenous healing practices, in some cases, these were combined with Western therapeutic interventions. Few programs had been formally evaluated, although the review found evidence that some of them had led to enhanced self-esteem, cultural connectedness and knowledge and skills.

4.6 Combining Healing and Therapeutic Interventions

One attempt to integrate ‘cultural healing’ with evidence-based therapeutic practices is the ‘healing model of care’ developed by the Aboriginal Drug and Alcohol Residential Rehabilitation Network (ADARRN), the peak body for Aboriginal residential rehabilitation facilities in NSW, in partnership with researchers at the National Drug and Alcohol Research Centre (NDARC), University of NSW (James et al. 2020). Staff and clients from six Aboriginal alcohol and other drug residential treatment centres worked with researchers, using a method known as Community-Based Participatory Research (CBPR, (Wallerstein and Duran 2006)) to define core treatment and organisational components in residential treatment services and in follow-up care, and to develop standardised assessment, data collection and evaluation models (Shakeshaft et al. 2018).

Fig. 4.1

Source Shakeshaft et al. (2018: 82)

Treatment and organisational components of a healing model of care.

A key outcome of the project was a ‘healing model of care’ developed in the first instance at Orana Haven treatment centre and adopted by the other five centres. The model was made up of six treatment components and three organisational components. The central treatment component was ‘healing through culture and country’. As shown in Fig. 4.1, this was linked to five other components: therapeutic activities, case management, life skills programs, time out from substances and aftercare support.

These components, as Fig. 4.1 shows, were supported by three organisational components covering governance, network linkages and staff skills. The steps involved in implementing, monitoring and assessing each of these treatment and organisational components were set out by Shakeshaft et al. in two program logic models developed in consultation with service providers and clients (Munro et al. 2017; Shakeshaft et al. 2018). One defined core treatment components, the other organisatonal level components. The first of these is reproduced in Table 4.1 on pages 118–119.

Table 4.1 Standardised program logic model of core treatment components and flexible program activities

The report’s authors argue that the program logic models have applicability beyond the six treatment facilities for which they were designed, not by prescribing a single treatment regime, but by providing a framework that identifies the necessary core components of a successful program. How those components will be implemented, the report suggests, will vary according to local conditions and needs (Shakeshaft et al. 2018).

4.7 Non-residential Treatment

This chapter has shown that treatment options for Aboriginal people with alcohol and other drug problems have historically been dominated by residential treatment and rehabilitation programs. In recent years, however, increasing attention has been paid to developing non-residential treatment options. Gray et al. reviewed findings from five such projects, each of them set up and evaluated as a trial (Gray et al. 2014). Services delivered included screening and brief intervention, case management, pharmacotherapy and psychological and social support. While each of the programs encountered implementation barriers arising from tight time-frames and associated difficulties in recruiting and retaining staff, they also demonstrated that, with funding support, programs could be established to meet a genuine demand for treatment.

For example, one of the trial programs—known as The Grog Mob and administered by the Central Australian Aboriginal Congress in Alice Springs—offered three streams of care: pharmacotherapy, psychological counselling and social support (d’Abbs et al. 2013). A total of 129 clients were referred to the program during the evaluation period, 49 of whom consented to have their de-identified data used in the evaluation. Of these, 19 clients received one or more streams of care, while the remaining 30 had not participated in any of the three streams of care at the time of evaluation. Psychological counselling was the most frequently used stream, taken up by 16 clients; by contrast, only six clients received pharmacotherapy—a lower number than anticipated by the program’s creators (d’Abbs et al. 2013). Of the 19 clients who had received one or more interventions, 15 (78.9%) reported that they had stopped or reduced their alcohol intake following participation in the program—but so too did 70% of those who did not receive any of the streams of care, leaving the evidence, hampered as it was by low numbers and a short time-frame, equivocal. This, and a need to understand an apparent reluctance among GPs to prescribe pharmacotherapies for Aboriginal clients, were two key findings from the study.

More generally, Gray et al. concluded from the five trials that, while they confirmed that there are no quick fixes for problematic alcohol use, beneficial programs can be established provided that they are controlled by Aboriginal people, culturally compatible, and resourced to a level sufficient to allow for recruitment and retention of staff (Gray et al. 2014).

In NSW, a group of researchers worked with a community-based alcohol and other drug treatment service in a rural town and an Aboriginal Community-Controlled Health Service towards developing and testing a treatment program that can be embedded into routine practice in a community-based treatment setting (Calabria et al. 2013, 2014, 2020).

The program is based on the Community Reinforcement Approach (CRA), adapted for use with Aboriginal clients following consultations with clients and service providers (Calabria et al. 2013, 2014). The original, US-based CRA is an evidence-based cognitive behavioural program for problem drinkers. Modifications requested by local Aboriginal people were for therapists to be local people, known and trusted by the community; for alcohol-related harms to be discussed sensitively; for detailed rather than brief interventions; for treatment sessions to talk about alcohol problems and the acquisition of skills to address these problems, and for follow-up support. Other modifications arising out of discussions with service providers included a reduction in technical language, an option for individual or group treatment sessions, and a reduction in the number of sessions (Calabria et al. 2014, 2020).

An evaluation conducted in 2013 involving 55 clients (24 of whom were Aboriginal), 58% of whom were followed up at 3 months, found that the program was considered acceptable and effective by clients, and associated with a statistically significant decline in self-reported alcohol and other drug use, a decline in psychological distress, and increased empowerment (Calabria et al. 2020). Although, as the authors acknowledge, the small sample in the study, its pre-test/post-test design and reliance on self-reported outcome measures all limit the weight that can be placed on the findings, the evaluation suggests that a suitably modified CRA-type program can feasibly be implemented in community-based alcohol and other drug treatment settings, and that it can be both acceptable to clients and contribute to improved outcomes.

More recently, Krakouer et al. conducted a systematic review of community-based alcohol and other drug (AOD) programs for Aboriginal and Torres Strait Islander peoples (Krakouer et al. 2022). The review included outreach programs and programs based in community centres or community health centres (including brief interventions) but excluded residential rehabilitation services on the grounds that they were not community-based. Outcomes relevant to the review were the impact and acceptability of programs. Seventeen studies met the selection criteria. Among these, only three demonstrated a statistically significant reduction in substance use; two of these focused on smoking cessation, while the third was the Calabria et al. study described above (Calabria et al. 2020).

The review found that outreach programs for alcohol and other drugs were generally well supported, partly because they enhanced access to treatment and partly because they promoted connections with kin and community networks. By contrast—and as noted in the previous chapter—brief interventions were generally not well received (Krakouer et al. 2022). The review noted the poor quality of most evaluations and called for both more high-quality evaluations and programs based on a holistic, whole-of-community, approach that incorporated family, kin and other cultural connections and that was led by Aboriginal people.

Similar flaws bedevil evaluations internationally. Jiwa et al. reviewed articles relating to community-based alcohol and other drug programs in Indigenous communities in Canada, the US, Australia and New Zealand published between 1975 and 2007 (Jiwa et al. 2008). A total of 34 articles were selected, most of them according to the authors’ opinion pieces and program descriptions (Jiwa et al. 2008: 1000). The authors argue that community-based prevention and treatment programs offer an alternative to residential treatment, which usually occurs away from clients’ own communities. However, they do not present any outcome findings from the studies reviewed. The review also uses the term ‘community-based’ loosely. As Blagg (2006) has pointed out, ‘community-based’ and ‘community-controlled’ are not one and the same. The label ‘community-based’ indicates that the program in question is situated in a community, but tells us nothing about who controls it. In Australia, this distinction has assumed increasing importance in recent years, as Aboriginal Elders and other community leaders have insisted on greater community control over what is studied and how studies are conducted, and greater recognition of Aboriginal knowledge and cultural perspectives (Purcell-Khodr et al. 2020).

Purcell-Khodr et al. conducted a systematic review of peer-reviewed studies of alcohol treatments delivered in primary care and other non-residential settings to Indigenous clients in Australia, New Zealand, Canada and the US (Purcell-Khodr et al. 2020). They identified 28 studies—17 from Australia, seven from the US and two each from Canada and New Zealand. Two-thirds (18) of the studies focused on treatment accessibility and acceptability, and the remaining one third on treatment effectiveness and/or implementation. While most Australian studies focused on early and brief intervention for non-dependent drinkers; US studies reported on interventions for alcohol-use disorders, including dependence. No studies, however, measured the effectiveness of brief interventions.

Two studies described home-based detoxification programs—an intervention which, in the view of the authors, showed promise. Three studies—all conducted in the US—reported on trials of relapse prevention medicines (disulfiram, naltrexone). The review noted that Aboriginal Australians are less likely to have access to pharmacotherapies than other Australians, and suggest that, on the basis of the evidence available, they may be a potentially effective and acceptable program if managed with a culturally-informed framework (Purcell-Khodr et al. 2020).

4.8 Supporting the Aboriginal Alcohol and Other Drug Workforce

Aboriginal alcohol and other drug (AOD) workers occupy roles that have been described as being ‘often exhausting, poorly paid and under-recognised’ (Roche et al. 2013). Roche et al. (2013) explored the workplace experiences of Aboriginal and Torres Strait Islander AOD workers in a study conducted in 2008 and 2009, involving 17 focus groups comprising a total of 121 participants (70 Indigenous, 20 non-Indigenous, 31 unspecified). Participants were drawn from most Australian jurisdictions, and included government and non-government services in rural, remote and urban settings.

Stressors identified in the study included the nature of drug and alcohol work; heavy workloads arising from juggling multiple roles and lack of role definition; ‘dual accountability’ to both their local community and employers; loss and grief in their own families’ lives and poor remuneration and lack of job security. The study recommended several workforce development strategies, including clinical supervision and mentoring; more flexibility in allowing workers to choose how to engage with clients; improved remuneration and greater recognition of Indigenous ways of working (Roche et al. 2013).

Compared with the situation reported by Brady in 2002 and discussed above (see Sect. 4.4), the level of training among Aboriginal AOD workers appears to have risen in recent years. Ella et al. (2015) conducted a descriptive study of the Aboriginal AOD workforce in NSW, which found that 74.5% of the 51 participants already had certificates or university qualifications, and 35.3% were currently receiving AOD-specific training. Almost all participants felt that they had the necessary experience to deal with AOD issues, but more than half felt that too much was expected of them and almost one-in-three reported receiving no formal supervision (Ella et al. 2015). The study made several recommendations, including a need to address discrepancies in salary and award conditions, clarify position descriptions and improve access to supervision.

Since both of these studies were conducted, residential rehabilitation facilities have been subject to further cutbacks in government funding, resulting in forced closures and adding to administrative difficulties. Most facilities are also forced to rely on short-term funding, which in turn necessitates 12-month contracts and associated problems in developing a stable, qualified workforce (Lee et al. 2017).

In NSW, support for the Aboriginal AOD workforce is provided by the Aboriginal Drug and Alcohol Network (ADAN), established in 2004 following a ‘Talking about Grog’ summit held in the previous year⁹ (Lee et al. 2017). ADAN’s objectives include supporting Aboriginal AOD workers across NSW; supporting Aboriginal individuals, families and communities in developing local strategies; enabling Aboriginal AOD workers to share information and resources and receive professional development and cultural support, and advising key stakeholders on policy development in the Aboriginal AOD sector.¹⁰

Another support network in the Aboriginal AOD treatment sector in NSW is the Aboriginal Drug and Alcohol Residential Rehabilitation Network (ADARRN), established in 2019 as a peak body for Aboriginal Community-Controlled residential rehabilitation services.¹¹

4.9 Evaluating Treatment Programs—At Home and Abroad

Despite nearly half a century of programs aimed at helping Aboriginal people recover from alcohol and other drug misuse, the evidence base for assessing the effectiveness of interventions remains modest. A 2010 review of studies of Australian Aboriginal alcohol and other drug residential treatment programs found evidence of a narrow range of treatment options, continuing difficulties relating to staffing, management and record-keeping, and little evidence of program effectiveness (Taylor et al. 2010). The review also noted a lack of programs in urban settings and post-treatment relapse prevention programs. In 2018, James et al. published a systematic review of studies of Indigenous drug and alcohol residential rehabilitation services in Australia, US, Canada and New Zealand, published between 1 January 2000 and 28 March 2016 (James et al. 2018). Most of the 38 studies they located were of low methodological quality, and only one reported a treatment outcome evaluation. Most of the studies were program descriptions. Most services provided multiple components, including education, life skills, cultural education and support. The 12-step AA treatment model was the dominant therapeutic component (James et al. 2018). Both Taylor et al. and James et al. called for the development of a broader range of evidence-based, culturally appropriate treatment models (Taylor et al. 2010; James et al. 2018).

Similarly, despite the long-standing and widespread use of mutual support groups—especially AA groups—in treatment programs for Aboriginal clients, there is little evidence of their effectiveness. Dale et al. conducted a systematic review of evidence from addiction recovery mutual support groups relating to Indigenous peoples in Australia, New Zealand, Canada, the US and Hawaii (Dale et al. 2019). They identified only four studies that met their selection criteria, all of them conducted between 2001 and 2006, and all conducted in the US with Native American Indian peoples and featuring AA. Although the four studies reported outcome variables such as the number of meetings attended, only one—an ethnographic study conducted in a single American Indian community—reported findings on the perceived usefulness and cultural suitability of AA—and these findings were mixed. Some participants felt that AA was congruent with their own cultural belief systems, while others considered its Christian underpinnings and use of concepts such as alcoholism made it more suited to western than Indigenous people (Dale et al. 2019).

Several systematic reviews have attempted—with limited success—to assess the impact of programs based on Indigenous cultures in international peer-reviewed literature. Rowan et al. (2014) conducted a scoping review of programs that used ‘cultural interventions’ to treat substance misuse among Indigenous populations. They defined cultural interventions as “Indigenous spiritual and healing practices or traditions introduced into residential or outpatient treatment centres to help achieve wellness following problematic substance use or addiction” (Rowan et al. 2014: 36). Wellness was conceptualised along four dimensions: spiritual, physical-behavioural, mental and social and emotional. The authors identified studies of nineteen programs, all of them based in Canada or the US—eleven residential, two that provided both residential and outpatient services, while the remaining six were either community-based or prison-based. All of the programs reviewed combined Western assessment, education, counselling and/or aftercare with cultural interventions. Among the latter, the most common were sweat lodges and ceremonial practices such as ‘sage, cedar or sweet grass smudges’ (Rowan et al. 2014: 37). All the programs were reported as leading to improvements in all dimensions of wellness, although the authors state that it is not possible from the studies to distinguish the impact of Western from cultural intervention components.

Leske et al. conducted a systematic review to assess the evidence base for culture-based interventions for Indigenous adults with mental and/or alcohol and other drug disorders in Australia, Canada, New Zealand and the US (Leske et al. 2016). The authors distinguished three types of interventions: (1) culturally unadapted—interventions that had not been modified for use with Indigenous populations; (2) culturally adapted—that is, programs adapted by, for example, administering in an Aboriginal language or using Aboriginal staff, or by involving the family in the treatment process and (3) culture-based—that is, based on cultural knowledge and traditional indigenous healing practices.

Sixteen studies met their selection criteria: seven in the US, four in Australia, four in New Zealand and one in Canada. Eight studies—including most of the US and Canadian studies—evaluated culturally unadapted programs. Seven studies evaluated culturally adapted programs, while the remaining study evaluated a culture-based program in the US. All the studies reported improvements in at least one of the outcome measures used. However, the authors concluded that it was not possible to compare findings or programs for methodological reasons, in particular, poor study design, in some cases small, non-probabilistic samples, and diversity of both program components and outcome measures. They also concluded that it was not possible, on the basis of the selected studies, to assess the extent to which cultural adaptations improved program outcomes (Leske et al. 2016).

Another recently published study reviewed the limited literature on the lived experience of Aboriginal clients of AOD services in Australia (Heath et al. 2022). The review examined 27 studies, from which the authors drew three key themes. The first was the importance of cultural activities and cultural reconnection in programs; the second was the value of holistic and strengths-based approaches that enhanced confidence and a sense of pride among clients and provided them with opportunities for change, for example, through components of life skills. The third theme was the importance of organisational aspects of the program, such as having access to experienced Aboriginal staff who demonstrated empathy and the capacity to understand clients’ needs (Heath et al. 2022).

Evaluations of Aboriginal treatment programs face a number of significant hurdles. Firstly, Aboriginal clients tend to bring a complex mix of needs and problems to treatment, as well as their alcohol or other drug use (Munro et al. 2017). A 2014 report by the National Indigenous Drug and Alcohol Committee (NIDAC) observed that these typically include physical health issues, mental health issues including grief and trauma, legal issues, cognitive impairment, family and other relationship issues, child protection issues, housing problems and unemployment (National Indigenous Drug and Alcohol Committee (NIDAC) 2014). Munro et al. (2017) examined admissions to a remote Indigenous rehabilitation facility in NSW and noted an increasing number and proportion of clients referred through the criminal justice system as well as high levels of multiple needs. Most clients were found to have at least two co-occurring risk factors, with 69% self-reporting polydrug use (mainly methamphetamines, alcohol and cannabis) and 51% reporting a current mental illness. Secondly, and in light of these needs, programs typically include multiple components, including counselling, life skills programs and case management. To link observed outcomes with specific program components under these conditions is methodologically difficult, if not impossible. The challenge is compounded by a third common feature: healing is by its very nature a protracted process rather than a one-off event, with multiple aspects occupying multiple domains, including social, emotional, cultural and spiritual dimensions (McKendrick et al. 2017). Fourthly, the accepted methodological tools for assessing treatment efficacy in mainstream research, such as randomised control trials and quantifiable biomedical indicators, are cultural products of the dominant society. In a context shaped by colonisation, contemporary power differentials, and differing cultural values, they can be resisted as being, at best, insensitive to Aboriginal cultural priorities and, at worst, instruments of continuing domination.

Chenhall (2008) argues that what constitutes ‘treatment’ in these settings is, in any case, not limited to the formal therapeutic components of the program. He notes that Aboriginal residential treatment and rehabilitation programs can be viewed as modified therapeutic communities—that is, they combine a structured daily regimen, designed to encourage personal responsibility, self-help and the use of peers as role models, with group psychotherapy, case management and culturally appropriate treatments. In such a setting, Chenhall argues, ‘treatment’ is woven into the informal processes and structures of everyday life in the community, in particular, the processes through which privileges are bestowed and withdrawn in response to compliance with, or deviation from, the espoused values of the community. In Chenhall’s view, evaluation designs that do not consider these aspects of treatment fail to describe what actually happens in the program (Chenhall 2008).

Chenhall and Senior (2013) attempted to build on these insights in a study based on ethnographic fieldwork and semi-structured interviews with staff and board members from three residential rehabilitation facilities located in the NT, northwest Australia and southeast Australia, respectively. The objective was to understand the key components of treatment as implemented in these facilities and barriers to effective outcomes. Two of the programs used an AA-based treatment approach, combined with other components such as education and life skills. Most treatments were group-based, with little one-on-one counselling. There was a broad agreement regarding the importance of Aboriginal culture, but differences in what this was taken to mean. In one case, because the program was run by Aboriginal people for Aboriginal people, it was considered by definition to be culturally appropriate, while staff from another organisation questioned the relevance of cultural ‘appropriateness’ on the grounds that, prior to European colonisation, Aboriginal cultures did not have to deal with severe substance misuse. At another facility, staff argued that cultural sensitivity, rather than appropriateness, was the quality required and that this involved interactions between staff and residents being conducted in a ‘safe and understandable way’ (Chenhall and Senior 2013: 89). Services were found to be well connected with other agencies, but there was little evidence of aftercare or follow-up, mainly because of resource limitations. The authors identified this as an important gap, and also stressed the need for strong and stable leadership. Finally, the physically constructed space of the facility was found to be important in influencing whether or not particular forms of treatment including counselling, could take place (Chenhall and Senior 2013).

One response to the challenges of evaluating Aboriginal healing programs is the Growth and Empowerment Measure (GEM), a measurement tool initially devised in conjunction with a program known as the Family Wellbeing Program (FWB) - (Hasswell et al. 2010). The FWB aims to enable participants to regain control over their everyday lives through physical, emotional, mental and spiritual transformations (Tsey et al. 2002, 2003, 2004, 2005). It has been implemented in several settings around Australia and has been evaluated in qualitative designs. The GEM is a quantitative measurement tool, incorporating dimensions of empowerment as defined by Aboriginal FWB participants. It consists of two scales. The first is a 14-item Emotional Empowerment Scale (EES14) designed to document the extent to which a person experiences well-being in various aspects of everyday life. The second comprises 12 ‘empowerment scenarios’ (12S) designed to gauge the degree to which a participant has changed subjectively in relation to functional areas of everyday life, as identified through prior qualitative research. Hasswell et al. (2010) conducted a psychometric validation of the GEM with a convenience sample of 184 Aboriginal and/or Torres Strait Islander people, drawn from urban, regional and remote communities in Queensland, the NT and NSW. The validation study also included a 6-item Kessler Distress Scale (K6) previously used in Indigenous wellbeing surveys and screening tools. Psychometric analyses corroborated the validity and reliability of both the EES and 12S scales and led researchers to distinguish four subscales: labelled self-capacity, inner peace, healing and enabling growth and connection and purpose, respectively.

Berry et al. (2012) used the GEM as one of three outcome measures—along with the Kessler 10 Psychological Distress Scale (K10) and a Drug Taking Refusal Self-Efficacy Scale (DTCQ-8)—in evaluating a 16-week residential AOD treatment program located on the south coast of NSW. The baseline study sample consisted of 57 Aboriginal and 46 non-Aboriginal male clients, although attrition saw this reduced to 34 participants at 16 weeks. Data was collected at three time points: baseline, 8 and 16 weeks. The study found statistically significant improvements on all measures between baseline and 8 weeks, and on most measures—including all four GEM subscales—between 8 and 16 weeks (Hasswell et al. 2010).

Blignault and Williams (2017) argue that program evaluations that are led by and responsive to Aboriginal and Torres Strait Islander communities need to be designed and implemented differently from mainstream evaluations:

High quality evaluations will be rigorous and incorporate Indigenous perspectives and values. Timeframes, methods, relationships between evaluators and stakeholders, and the identification and measurement of outcomes all need to be context sensitive. Challenges include definitions of healing, diversity of landscapes and programs, and data collection. Qualitative open-inquiry models and data collection methods, which preference and support Indigenous worldviews and ways of creating and sharing knowledge, work well in this space. Working ethically and effectively in the Indigenous healing space means emphasising and enabling safety for participants, workers and organisations—adopting a trauma-informed approach as well as ensuring culturally sensitive methodologies and tools (Blignault and Williams 2017: 9).

One evaluation approach that seeks to meet these requirements is the Ngaa-bi-nya framework proposed by Williams for evaluating Aboriginal and Torres Strait Islander health and social programs (Williams 2018). The term Ngaa-bi-nya means to examine, try and evaluate in the language of the Wiradjuri peoples of central NSW. The approach is said to be grounded in a holistic view of health and wellbeing and to privilege Aboriginal and Torres Strait Islander perspectives. It comprises four domains: landscape, resources, ways of working and learnings. The framework contains prompts within each domain, designed to elicit compliance with good practice. For example, the ‘landscape’ domain directs evaluators to gather data on the history of the local area and the program under review; the demographic and socio-economic environment, availability of services and programs, and the extent to which local Indigenous people have been involved in identifying local needs and priorities. Overall, the framework is intended to identify ‘critical success factors’ in programs targeting Aboriginal people (Williams 2018: 8).

Chenhall and Senior (2012) trialled the use of a Quality of Life measure to gauge treatment outcomes among 25 clients in an Indigenous residential treatment facility in the NT. Under the measure, known as SEIQoL-DW,¹² clients were asked to nominate five areas of their lives that they considered important and to rate their own functioning in each of these domains on a 10-point scale. Graphical techniques were then used to enable clients to weigh the relative importance of each domain. The results of these activities were then transformed into a score. In this study, frequently nominated domains included relationships with family, cultural activities, work opportunities, managing money, stopping drinking and specific issues such as regaining drivers’ licences.

In principle, comparisons between clients’ profiles before and after treatment enable changes to be measured, not against externally imposed treatment assessment criteria, but against clients’ own values and concerns. In this instance, most of the 25 participating patients departed from the treatment program before the planned exit date, thereby making it impossible to assess change in all but a small number of cases (Chenhall and Senior 2012).

4.10 Summary and Conclusions

In this chapter, we have traced the emergence and evolution of several approaches to the treatment and rehabilitation of Aboriginal people with established patterns of alcohol misuse. All of these approaches labour under a considerable handicap, insofar as they do not and cannot address the conditions that give rise to alcohol and other drug misuse in the first place. At the same time, all of them attempt to support individuals and/or families in their efforts to regain control over their lives.

The dominant approach over most of the fifty years under review has been residential treatment based on the Twelve Steps and mutual support principles of Alcoholic Anonymous. In more recent years, treatment programs grounded in various forms of cultural healing have been introduced, designed to deal with the unresolved, intergenerational trauma that is widely seen as underlying alcohol and other drug misuse among Aboriginal people. In many instances, these programs combine Aboriginal and western therapeutic models.

Two other themes are woven into this account: one is the ongoing need for resourcing, training and supporting the Aboriginal alcohol and other drug treatment workforce. While the level of training among AOD workers appears to have risen in recent years, treatment facilities continue to struggle to provide adequate remuneration, working conditions and workplace support. A second theme is a continuing quest for ways of assessing treatment effectiveness in a manner that combines methodological rigour with cultural sensitivity.