Psychologists’ experiences towards culturally responsive practices to strengthen social and emotional wellbeing with Aboriginal and Torres Strait Islander clients

Figures & data

Table 1. Demographic comparison of study participants and AHPRA psychology workforce data.

Demographics	AHPRA Demographics (N = 46,465) %	Total Study Demographics (N = 108) %	Chi = Squared (df)	p-value
Indigeneity			233.65 (1)	<.001
Indigenous Australian	0.7	13
Non-Indigenous	98.3	87
Gender			2.400 (2)	.121
Female	80.5	73.2
Male	19.5	25.8
Age Group			18.28 (9)	.032
<25	2.6	2.6
25–29	11.9	12.2
30–34	13.2	9.6
35–39	14.0	21.7
40–44	13.3	7.0
45–49	11.5	8.7
50–54	10.1	7.8
55–59	7.2	3.5
60–64	6.4	5.2
65–69	4.7	4.3
70–74	3.1	0
75–79	1.5	0.9
80+	0.5	0.9
States of Employment			12.895 (5)	.024
QLD	18.2	12.2
NSW	32	12.5
VIC	28	21.7
TAS	1.8	33.9
SA	4.9	3.5
ACT	2.5	3.5
WA	10.5	5.2
NT	0.6	8.7
Missing	1.3	2.6
Registration Types			7.63 (2)	.022
Provisional	16.3	23.5
Registered	79.8	76.5
Other	4.0	0
Areas of Endorsement			65.24 (4)	<.001
Clinical neuropsychology	5.4	21.8
Clinical psychology	71.5	67.3
Forensic psychology	4.0	5.5
Counselling psychology	6.4	5.5
Community psychology	0.3	0
Ed and dev psychology	5.5	0
Health psychology	2.1	0
Organisational psychology	4.1	0
Sport and exercise psychology	0.7	0

Table 2. Comparison of demographic variables for participants separated by group and overall.

	Group 1 Aboriginal psychologists (n = 15)		Group 2 Non-Indigenous psychologists, with experience with Indigenous clients (n = 73)		Group 3 Non-Indigenous psychologist, with no experience with Indigenous clients (n = 20)		Total Sample (n = 108)
	n	%	n	%	n	%	n	%
Gender
Female	13	86.7	59	81.9	17	85	89	83.2
Male	2	13.3	13	18.1	3	15	18	16.8
Missing	0		1		0		1
Country of birth
Australia	15	100	55	76.4	14	70	84	78.5
Overseas	0	0	17	23.6	6	30	23	21.5
Missing	0		1		0		1
Main Language
English	15	100	71	97.3	20	100	106	98.1
Other	0	0	2	2.7	0	0	2	1.9
Temporary Residency
Yes	0	0	1	1.4	1	5	3	2.8
No	15	100	72	98.6	19	95	105	97.2
Primary Psychology Role
Education	1	6.7	7	9.6	5	25	13	12
Direct client services	13	86.7	61	83.6	15	75	89	82.4
Managerial	1	6.7	5	6.8	0	0	6	5.6
Not applicable	0	0	0	0	0	0	0	0
Secondary Psychology Role
Education	5	33.3	18	24.7	8	40	31	28.7
Direct client services	3	20	19	26	1	5	23	21.3
Managerial	1	6.7	5	6.8	2	10	8	7.4
Not applicable	6	40	31	42.5	9	45	46	42.6
Work across sectors
Public	4	26.7	21	30	2	11.1	27	26.2
Private	7	46.7	20	28.6	5	27.8	32	31.1
Both	4	26.7	29	41.4	11	61.1	44	42.7
Missing	0		3		2		5
States of Employment
QLD	3	20	6	8.3	2	10.0	11	10.3
NSW	1	6.7	20	27.8	0	0	21	19.6
VIC	5	33.3	30	41.7	15	75.0	50	46.7
TAS	1	6.7	2	2.8	0	0	3	2.8
SA	0	0	1	1.4	0	0	1	0.9
ACT	0	0	1	1.4	2	10.0	3	2.8
WA	2	13.3	6	8.3	0	0	8	7.5
NT	1 2	6.7 13.3	2 4	2.8 5.6	0 1	0 5	3 7	2.8 6.5
Multiple states
Missing	0		1		0		1
Geographical areas of work
Metropolitan	7	46.7	50	68.5	18	90	75	69.4
Regional	2	13.3	6	8.2	1	5	9	8.3
Rural	1	6.7	3	4.1	0	0	4	3.7
Remote	0	0	3	4.1	0	0	3	2.8
Multiple	5	33.3	11	15.1	1	5	17	15.7
Registration or Endorsement type
Provisional psychologist	6	40	10	13.7	10	50	26	24.1
Registered psychologist	2	13.3	28	38.4	3	15	33	30.6
Clinical neuropsychology	0	0	10	13.7	0	0	10	9.3
Clinical psychology	7	46.7	18	24.7	6	30	31	28.7
Counselling psychology	0	0	1	1.4	1	5	2	1.9
Double endorsement	0	0	6	8.2	0	0	6	5.6
Psychology training pathway
Doctorate degree	3	20	20	27.8	10	52.6	33	311
Master degree	9	60	31	43.1	7	36.8	47	44.3
5 + 1 Internship	0	0	4	5.6	1	5.3	5	4.7
4 + 2 Internship	3	20	15	20.8	1	5.3	19	17.9
Other	0	0	2	2.8	0	0	2	1.9
Missing	0		1		0		2

Table 3. Descriptive statistics for categorical variables between groups using exact hypothesis testing.

	FFH	p-value	V	N
Gender	.18	1.00	.880	107
Country of birth	5.79	.052	.220	107
Main language	.60	1.00	.095	108
Temporary resident	2.70	.2.45	.127	108
Principle role in psychology	4.29	.317	.153	108
Secondary role in psychology	5.63	.444	.152	108
Work across sectors	5.51	.232	.166	103
State of employment	25.17	.017	.342	107
Geographical areas of work	8.81	.256	.216	108
Registration type	20.43	.003	.319	108
Area of endorsement	6.01	.158	.217	80
Psychology training pathway	7.47	.426	.202	106

Note – bolded p-values indicate significance at the p = < 0.005 level.

Table 4. Comparison of means and standard deviation of continuous variables separated by group and overall sample.

	Group 1 Aboriginal psychologists (n = 15)		Group 2 Non-Indigenous psychologists, with experience with Indigenous clients (n = 73)		Group 3 Non-Indigenous psychologist, with no experience with Indigenous clients (n = 20)		Total Sample (n = 108)
	M	SD	M	SD	M	SD	M	SD
Age
Range in years	24–65		22–83		23–60		22–83
Average in years	42	12.8	40.1	13.1	41.3	10.5	40.7	12.8
Sector work (hours)
Public	27.3	11.5	28.4	10.3	23.2	14.4	27.7	10.8
Private	23.4	14.7	20.6	11.8	20.7	9.7	20.7	11.9
Years worked as psychologist	8.3	7.3	12.8	11.1	10.9	5.1	10.9	10.1

Table 5. Psychology clinics and organisations methods to identify Aboriginal and Torres Strait Islander clients.

Main Themes	%	Quote Example
Intake or administration	36.6	“A screening question is asked at intake”
Self-reported	20.8	“Clients self-identify”
File or referral	13.9	“Via medical records”
Initial assessment	15.8	“I ask about all my client’s cultural identity in my initial session”.
Network connections	5.9	“Word of mouth, family-connections”
Unsure or do not collect	6.9	“They don’t”

Note: n = 101 missing = 7

Figure 1. Participants’ perspectives of the need for psychological practice adjustments when working with Aboriginal and Torres Strait Islander clients.

n = 113, missing = 2

Figure 2. Non-indigenous participants reported ability to provide competent psychological therapy to Aboriginal and Torres Strait Islander clients based on current cultural knowledge, understanding, and awareness.

Table 6. Challenges experienced by psychologists when working with Aboriginal and Torres Strait Islander clients.

	Main Themes	Percentage*	Challenges Experienced
Aboriginal psychologists (n = 15)	Ethical Implications	33%	Initial contact or engagement Dual relationships Informed consent Confidentiality Interface of cultural and ethical practices not aligning
	Complex Presentation	40%	Complex multilayered presentations Complex environmental factors High levels of intergenerational trauma Client experience resonates with personal experience.
	Systemic or Organisational Barriers	100%	Lack of personal/government funding to continue. Layered systemic disadvantage Negative past experiences in the health system Lack of Indigenous knowledge requirements by regulatory bodies Client mistrust of systems Lack of Aboriginal psychologists and staff in the systems Lack of culturally safe mental health services
Non-Indigenous psychologists (n = 59 missing = 14)	Complex Presentation	52.5%	More neurodevelopmental challenges than non-Indigenous Complex trauma presentations Historical impacts Getting a thorough history from clients Parental involvement with younger clients Difficulty engaging clients Difficulty interpreting non-verbal cues Diversity within acculturation Comorbid health issues Family and community obligations impacting engagement and progress Rapport building Absence of basic human rights
	Systemic or Organisational Barriers	54%	Clients deep mistrust of systems Inadequate diagnostic procedures (overdiagnosed) Interface of culture and ethical practice Receiving conflicting best practice training Difficulty attending appointments Lack of flexibility in organisation policies Reduced mental health literacy Working appropriately within multi-disciplinary teams Restrictions imposed by the Medicare model Interface of implementing best practice within funding models Strict and unethical justice system policies and procedures Negative past experiences in the health system Service engagement
	Under Resourced	29%	Less access to services Less opportunity Less resources Less evidence-based therapies/interventions Less services for referral and support Limited interpreter services Additional time burden on psychologists to educate themselves and find appropriate resources Lack of Indigenous AHPRA professionals Lack of appropriate supervisors
	Lack of Knowledge	25.5%	Not understanding cultural values/traditions Not understanding the connection to Country Fear of perpetuation of unintentional burden or harm Not familiar with culture-bound syndromes Uncertainty of how to gather information appropriately Unsure of correct language and terminology Lack of confidence Inadequate university education/training for psychologists Impact of Aboriginality in presentation Applying a Cultural lens Feeling ill-equipped to respond to revelations so far removed from professional knowledge or experience. Language barriers Being conscious of personal bias, privilege, and assumptions

*Note – There was no limit on how many themes participants could address in response to this open-ended question, therefore, the percentage will not equal 100, and rather reflects the percentage of participants who referenced the theme in their open-ended response.

Bolded responses represent a commonly report theme across both groups.

Table 7. Thematic comparison of suggested successful psychological practice adjustments when working with Aboriginal and Torres Strait Islander clients between Aboriginal and non-Indigenous psychologists.

Participant Group	Theme	Percentage*	Suggested Successful Practice Adjustments
Aboriginal psychologists (n = 15)	Shared Knowledge	33%	Understanding how culture shapes Aboriginal and Torres Strait Islander peoples Identity Trauma Systemic barriers Historical barriers
	Indigenous Worldviews	86%	Applying: Strengths-based approach, Working holistically, Incorporating the SEWB framework Ensuring self-determination, Working collaboratively with family, community, or services, when necessary, Incorporating a trauma-informed approach.
			Removing (when appropriate): Diagnostic lens Westernised epistemologies, Scientist-practitioner model when appropriate.
	Community Focused	20%	Incorporating and addressing: Community healing Local supports Social determinants of health
	Therapeutic Process	73%	Participants suggested: Need to move more slowly. Build deeper trust and a secure therapeutic relationship. Increased self-disclosures. Establishing shared community connections Carefully exploring how the community relationships differ from the therapeutic relationships. Take a horizontal, collaborative, and informal approach. Address diversity within the Aboriginal and Torres Strait Islander communities to understand acculturation. Sessions outside in nature. Daddiri (Deep listening) Make information simple and manageable. Use visual cues. Undertake cultural mapping. Considering the language used to communicate psychological information. Utilising narrative and storytelling approaches. Walking alongside the clients, meeting them where they are at.
Non-Indigenous psychologists (n = 57, missing = 16)	Personal Characteristics	30%	Important Characteristics: Empathy Honesty Humility Openness Curiosity Advocacy Flexibility Willingness to learn Respect Non-Judgemental Genuine Integrity Humour
	Interventions and Approaches	58%	Successful outcomes after implementing: Systemic/Group therapies Narrative therapy Art and play therapy Using SEWB frameworks Less formal and structured sessions Reflexivity to changing needs of clients Cultural mapping Daddiri (deep listening) A mindful state Trauma-informed care Acceptance Client-centred approach Collaborative formulation with client and wider community of appropriate
	Therapeutic Processes	87%	Participants suggested: Increase self-determination Increased self-disclosures Walking alongside the clients Holistic, bigger picture approach Strengths-based approach Moving at a slower pace in session Establish and explore common ground more Remove diagnostic lens Yarning style communication Less reflective feedback Extended Information gathering Extended time spent rapport building Explicit communication of roles Explicitly addressing confidentiality and consent Open invitation for community to attend sessions if the client grants permission Invite feedback and corrections from client Explaining reasoning behind questions asked Adjust language used Explore client’s past experiences with psychologists Sitting next to the client as opposed to opposite Consider cultural norms around eye contact Increased awareness of psychologist’s non-verbal cues
	Knowledge and Professional Development	56%	Understanding, exploring, and/or addressing: Connection to culture Historical and continuing impact of historical events Underlying assumptions Generalised information in cultural competency training Increased exposure to grief and loss Placing caveats in assessment reports addressing scientific and ethical implications The use of invalid psychometric assessment tools. Unlearning Westernised education and relearning decolonised practice methods Seek Aboriginal supervision, cultural consultants, or Aboriginal colleagues in the workplace for guidance on cultural aspects of clients Professional development opportunities Reduce power imbalance by “dressing down” Increase accessibility (e.g., provide taxi vouchers) Aboriginal and Torres Strait Islander worldviews Importance of Country Cultural identities are individual and diverse
	Cultural and Environmental Considerations	35%	Consider: Flexible locations for sessions (e.g., outside) Accounting for spirituality Connecting with community elders Work collaboratively with Aboriginal services Cultural engagement as a protective factor Display Aboriginal art in the office Aiding connection to community for clients who have relocated Offer home visits Engage with community outside of individual clients to deepen knowledge and strengthen personal connections

*Note – There was no limit on how many themes participants could address in response to this open-ended question, therefore, the percentage will not equal 100, and rather reflects the percentage of participants who referenced the theme in their open-ended response.

Bolded responses represent a commonly report theme or suggestion across both Aboriginal and non-Indigenous psychologist groups.

Table 8. Thematic comparison of experience of unsuccessful psychological practice adjustments when working with Aboriginal and Torres Strait Islander clients between Aboriginal and non-Indigenous psychologists.

Participant Group	Theme	Percentage*	Experience of Unsuccessful Practice Adjustments
Aboriginal psychologists (n = 15)	Therapeutic Process	40%	Rushing Not spending enough time building rapport Exploring Emotions too quickly Being too direct Sterile therapeutic environments
	Intervention or Approaches	26.5%	Adjustments to cultural practice when clients are seeking a diagnosis. A pedagogical approach Surface level changes to Western ways of working
	Systemic or Organisational Barriers	20%	Inflexible systems and policies to provide best practice.
Non-Indigenous psychologists (n = 51 missing = 22)	Therapeutic process	39%	Not adjusting for cultural differences Speaking too much Spotlighting during training and education contexts Communicating poorly, increasing client’s shame Blank face acceptance Ignoring the power imbalance Being impatience Waiting for clients to attend the clinic Being too fearful to attempt adjustments Not checking in with clients for clarity Not building enough rapport before progressing Not giving clients choices in their care Directly explaining Indigenous frameworks (questions work better) Being too conservative Confined/small counselling spaces.
	Identity	23.5%	Being ingenuine as the psychologist Generalised group assumptions based on identity Not addressing psychologist’s white privilege Imposing personal views and stereotypes
	Systemic or Organisational Barriers	25.5%	Referring directly to Indigenous services once identified Not addressing social/systemic issues Formal paperwork Accepting and applying DSM definitions or criteria Assuming referral reason is the only challenge they are experiencing Differing perceptions of confidentiality GP referrals for medical intervention without client having a relationship with the GP Using inappropriate resources Not understanding the services available to clients Not understanding roles of people involved with clients Emphasising organisational policy and procedure Clients having to educate psychologists about culture
	Interventions or Approaches	12%	Short-term therapies addressing symptoms. Using CBT Applying Westernised attachment theories Using a deficit approach and language

*Note – There was no limit on how many themes participants could address in response to this open-ended question, therefore, the percentage will not equal 100, and rather reflects the percentage of participants who referenced the theme in their open-ended response.

Bolded responses represent a commonly reported theme by both groups.

Data availability statement

The participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available.