The legacy of trauma

Alice Chang talks about her new job working mainly with indigenous young people with mental health problems in northern Australia.

Generations of marginalisation and trauma mean mental illness in Australia’s northern-most province - home to many indigenous people - often involves extreme and complex cases.

Yet there are few mental health specialists working in the area and there is no child and adolescent in-patient unit. Patients have to be flown two and half hours to Brisbane for treatment.

Often the most harrowing cases are those of children and teenagers. This is where Alice Chang [2008] comes in. She worked in the region while she completed her medical training after finishing a masters in Public Health at Cambridge and is set to return there this year.

“A lot of the kids are in care or fostered. There is social chaos due to the sad history of their treatment in Australia,” says Alice. “Children as young as six or seven have got substance abuses issues or have attempted suicide.”

The physical impact of substance abuse can be huge given the nature of the most commonly used substances. Many sniff paint or drink methylated spirits among other substance abuse which can cause long-term cognitive and physiological damages. Abuse of such substances is linked to increased suicide risk and indigenous people often commit suicide in very violent, public ways.  “They don’t just take an overdose. They tend to hang themselves in a public area as a statement of the sorrows passed down from their families and the tragedies they have experienced in their lives,” says Alice.

Training

Alice did all her medical training in rural and regional Australia.  “I wanted to do medicine to help people. I didn’t want to sit in a city clinic writing repeat prescriptions for people who have an oversupply of doctors. Australia is a vast country with a small area of liveable land. There are vast distances of nothingness where they need doctors the most. I always thought that once I had finished my training I would go back and work where there are not many doctors, particularly specialists.”

Alice, who moved to Cairns while she was pregnant and finishing her five years of specialist psychiatry training, will be the only child and adolescent specialist in Cairns. Due to the lack of a child and youth mental health in-patient unit, patients with serious illnesses are flown to Brisbane. This can result in serious educational and developmental disruption to the children and hardship to their family’s lives if they are admitted for a long period. “There is the Flying Doctor Service [which Alice has done] for emergency cases, but mental health issues tend to be more chronic,” she says.

Her work will cover everything from separation anxiety and bullying to Autism Spectrum Disorder, ADHD and Anorexia Nervosa. Treatment for indigenous teenagers with mental health issues tends to involve the whole community. “Their family structure has often been destroyed. Their parents may be substance abusers or have left the community. They are often being looked after by grandparents. They have either done something very harmful to themselves or are referred by a local community worker,” she says.

Mental health

Alice’s decision to specialise in mental health was the result of her time in Cambridge where she studied with the support of a Gates Cambridge Scholarship.

She had already qualified as a doctor and had established a youth for youth medical volunteer charity that gives young people the opportunity to volunteer in rural communities both in Australia and overseas when she had her Gates interview. It happened in an unusual setting.

She had worked as a medical volunteer in a range of countries and was based in a rural part of China working on a hand, foot and mouth disease outbreak so she did her interview on her mobile in a van in the middle of a rice field with cows nudging at the car window. Alice, who has twice been named a Young Australian of the Year, had intended to specialise in opthalmology, as her husband does, when she started her masters.

However, when she was doing her thesis she realised the need for mental health doctors was greater among indigenous people. She had always planned to return to Cairns and a job came up in mental health after she completed her masters and it all fitted perfectly.

She says the indigenous community has a different view of mental health. “Their definition of mental illness is different to that of the general population due to their belief in dreamtime, a place beyond time and space in which the past, present, and future exist wholly as one,” says Alice.

Many of the cases she has dealt with in the past have been extreme and are usually associated with substance abuse and multi-generational trauma associated with their history and with racism. These include copycat suicides which hit the community harder because everyone is so closely connected.

Stigma

Rural communities often neglect mental health issues, she adds.“They tend to adopt a stoic approach and say you have to live with it. There’s also a lot of stigma, particularly of illnesses like schizophrenia and depression and people do not want to talk about it. In cities there is greater acceptance as people live with all sorts of people,” says Alice.

To combat some of that stigma Alice has started a weekly community radio programme to talk about symptoms, treatments and where to get help. She is also a regular on other national radio programmes talking about health issues, whether that is seasonal affective disorder or narcissism. “The aim is to make psychiatry less scary,” she says. She also visits schools and talks to children and their teachers.

Alice has a 14-month-old toddler and took a part-time job in Brisbane to ease herself back to work. That means she has to live away from home two days a week. Her post is at a mental health unit in a Brisbane children’s hospital and involves direct therapy with patients and their babies who have been referred to her and she follows John Bowlby’s theory of attachment.

She works with mums to be, those who have just given birth and babies aged up to four. “I work with a wide spectrum of trauma and mental illness,” she says. “Many of the babies are born into chaotic households and I work with the families.”

Alice assesses the patient child relationship through observation and helps mothers to improve their interactions with their children. She thinks it is vital to understand the mother’s background to help the child. Many of those she sees are from traumatic backgrounds and she wants to find ways to stop that cycle of trauma. Sometimes this can involve recommending the baby be taken into care, but this is always a last resort. “Parenthood challenges you day after day and brings up issues from the past which it might be difficult to face. It is not about judging families, but helping them to understand why they do certain things,” says Alice.

She hopes eventually to do a PhD and to work on public health policy issues and credits her time at Cambridge with making her aware of the importance of seeing the wider picture. “Clinical medicine is fantastic, but it only helps one person at a time,” she says. “The key to public health is prevention. Working with the most severe cases we are just trying to hold back the tide.”

Picture credit: Australia: Aboriginal Culture 002. Photo by Steve Evans from Citizen of the World. Creative Commons License via Wikimedia Commons.