Cultural safety for aboriginal and Torres Strait Islander adults within Australian music therapy practices.

Truasheim, Sian

Cultural safety is defined as "the effective delivery of services to people from another culture, as determined by individuals and groups from that culture" (Saggers et al., 2011, p. 18). Due to a history of harmful treatment from health professionals, it is particularly important to provide health services that Aboriginal and Torres Strait Islander people feel culturally safe accessing to encourage regular engagement in effective treatments (Isaacs, Pyett, Oakley-Browne, Gruis, & Waples-Crowe, 2010).

There is only a small amount of published work that discusses cultural safety in music therapy for Aboriginal and Torres Strait Islander clients, also known as First Australian people. The aim of this article is to increase consideration of cultural safety within music therapy programs accessed by Aboriginal and Torres Strait Islander peoples, and evaluate the potential for cultural safe music therapy programs through examining a pilot program that the author was a part of as a non-Indigenous music therapy student.

Understanding to Date

A Picture of Aboriginal and Torres Strait Islander Health

Since colonization in 1788, colonial practices such as removal from traditional land, persistent disadvantage, racism, separation of families, and oppression of culture have contributed to health and wellbeing inequality between non-Indigenous and First Australians (Saggers et al., 2011). First Australian adults experience greater hardship in social health (Australian Human Rights Commission, 2008; Gubhaju et al., 2013), two and a half times greater burden of illness (Snowdon, 2010), and 9-13 years shorter life expectancy than non-Indigenous Australians (Rosenstock, Mukandi, Zwi, & Hill, 2013). They also experience increased barriers to accessing health care such as language differences, a lack of cultural understanding, and racism (Elkin, 2011).

In response to colonial practices, there has been a shift to health care services owned and informed by the Aboriginal and Torres Strait Islander community in collaboration with non-Indigenous professionals (Bartlett & Boffa, 2005). An Aboriginal and Torres Strait Islander understanding of health guides these services, in which health includes "not just the physical well-being of the individual, but the social, emotional, spiritual and cultural wellbeing of the whole community" (National Aboriginal Health Strategy Working Party, 1989).

Cultural Safety in Health Care

While all clients bring culture to therapy, First Australian people require greater cultural consideration due to the historical and ongoing harm from health care services (Elkin, 2011). Cultural safety requires the evaluation of how well services meet culturally valued goals as evaluated by members of Aboriginal and Torres Strait Islander communities themselves (Saggers et al., 2011).

In contrast, culturally unsafe practice is "any action, which diminishes, demeans or disempowers the cultural identity and well-being of an individual" (Nursing Council of New Zealand, 2005, p. 4). Even well-meaning Western practitioners may provide culturally unsafe therapy if they view minority cultures as needing help, as this still harms clients through the disempowerment and negative views.

Models for Cultural Safety

A number of models for cultural safety with First Australians have been developed. Lippmann (as cited in Bin-Sallik, 2003) proposed that staff in a tertiary education setting should support systematic maintenance of an Aboriginal or Torres Strait Islander identity, creation of cultural spaces, and affirmative action to support university entry following culturally inappropriate secondary schooling. Within health care, this model suggests that additional staff should be available to support, that additional health care services are available to address a history of poor health outcomes, and that maintenance of cultural identity is supported within services.

After substantial consultation with the Aboriginal community, the Victorian Aboriginal Child Care Agency created a four part cultural safety model (Frankland, Bamblett, & Lewis, 2011) which requires joining back into one's own Aboriginal community, having Aboriginal people access power in society to be self-determined, creating greater relationships with land and culture, and recreating cultural products through creative media.

Ball's cultural safety model for speech-language and audiology services (as cited in Brascoupe & Waters, 2009) includes respecting and following cultural protocols, reflecting on and sharing about one's own personal identity, engaging in a process of learning and checking, ensuring therapy has a positive purpose for that particular client's life, and engaging in collaborative partnerships.

Music Therapy with Aboriginal and Torres Strait Islander Populations

Bann and Tait emphasise the need to appreciate others' values, accept others' experiences as valid, listen, learn from mistakes, and respect cultural protocols when considering First Australian people's perspectives in music therapy (Bann & Hadley, 2013; Tait & Hadley, 2013). Abad and Williams (2005) observed greater engagement of First Australian clients in Sing & Grow sessions when trust and rapport were developed, when there was a culturally welcoming and appropriate physical space, Indigenous staff involvement and clear staff training, and specific consideration of and support for cultural matters to support successful outcomes.

Didgeridoo playing resulted in significant improvements in respiratory functioning with a small sample of male Aboriginal school students with asthma (Eley, Gorman, & Gately, 2010; Eley & Norman, 2010; Eley, 2013), however, singing lessons did not result in significant improvements for girls. Staff involved also observed that the boys gained increased confidence and cultural awareness, and families reported increased confidence in accessing attached medical services (Eley et al., 2010; Eley & Norman, 2010).

The Clinical Service context

In 2012, the author was invited by an urban community-controlled Aboriginal and Torres Strait Islander health service to undertake a placement as part of her Masters of Music Therapy Degree. Part of this placement was spent with the chronic-disease self-management program for First Australian adults. The program was built around four gym-based exercise sessions per week, led by an exercise physiologist. Self-management education sessions lead by a variety of allied health professionals were offered prior to exercising twice a week. Education sessions included topics such as energy conservation, , anger management, and medication management. Music therapy's role was to provide another modality to support the clients' health and wellbeing. The frequency of the music therapy program was informed by the student's clinical placement, and totalled 12 weekly sessions of 45 minutes, post-exercise. Participants required a doctor's referral to join the overall program, but following this attendance was open.

Participants

Nine women and four men aged 39 to 77 years who were already attending the self-management program participated in music therapy. All had a range of chronic disease (see Table 1). Chronic disease refers to both physical and mental health conditions due to the potentially ongoing nature of both (Bertschy, 2009).

An Aboriginal health worker, a research assistant and two exercise physiologists who were regular staff at the program also participated as active group members in music therapy. This was to strengthen relationships between clients and staff as well as maintain equal power between these groups.

In the music therapy sessions

The music therapy student, in consultation with the placement supervisor, began the placement by attending the program once to observe and build rapport before facilitating the initial music therapy session. In this first session the author shared her background, her studies, and information about music therapy. Clients were then invited to share their musical preferences, their health needs and possible goals for music therapy, if they were comfortable. This discussion served as a form of group assessment to collect data about physical and mental health functioning, as well as client prioritised goals. From the discussion, the group identified common goals as increased social connectedness, improved physical health, and a need to share the program to promote improved community health.

Ongoing music therapy sessions had a set structure as a number of interventions continued over multiple weeks' and required time to give all participants a turn. First, a chorus of "G'day, G'day" by Slim Dusty was sung as a welcome song to orient the group. Following this, one group member each week shared a song that was meaningful to them. The music therapist first played the recorded version of the selected song which was followed by the group member discussing its importance, other participants' responses to it, and further exploration of any commonalities or bonds that arose. The song was then recreated live with the music therapist on guitar and vocals, and group members on percussion and vocals. Three weeks into the program, the group reported that they felt this was too slow as the total number of people attending music therapy grew, and that they would like to have two people share songs each week, played only once in the recorded, authentic form. This format was continued for the rest of the program.

Song-writing was discussed in the initial session as a way the group may meet their goal of sharing their experiences in the program and advocate for improved community health. The group chose to parody "G'day, G'day" as they reported they enjoyed it as the hello song and came to identify it with the group. Clients brainstormed ideas about joining the program, their current involvement, and hopes for the future, which were then structured into a chorus and two verses. When attendance was low, the group and the music therapy student sometimes postponed song writing until there was a more representative group present. Musical memory or concentration games were played instead, and these provided an opportunity for staff to show vulnerability and playfulness so as to strengthen their rapport with the clients.

Progressive muscle relaxation with music was introduced early in the program, and was incorporated into the end of every session to support improved mental health and reduced blood pressure. A staff member recommended the use of Geoffrey Gurrumul Yunupingu's music in this activity, and so a mix of western orchestral and cultural music was used in this section of the session. A simple farewell song was used to close the group each session.

Outcomes and Feedback

Physical health

Blood pressure readings were recorded prior to exercising, post-exercise/pre-music therapy, and following music therapy as a measure of physical health, as a number of clients expressed an aim to reduce their blood pressure. A REML (Restricted Maximum Likelihood) regression was conducted on participants' pre-exercise blood pressure readings, comparing the average resting blood pressure for the 12 weeks prior to the music therapy program to the average resting blood pressure during the 12 weeks of music therapy. While the whole multidisciplinary program likely affected blood pressure, this analysis offered one way of tracking changes correlated with the music therapy experience. There was a significant decrease in resting diastolic (minimum pressure during heartbeat) blood pressure of approximately 3.66 points (p=.049). There was a non-significant decrease in resting systolic (maximum pressure during heartbeat) blood pressure of approximately 3.82 points (p=.098). Providing further details about the analysis of the data is beyond the scope of this article, and that further data is available from the author on request.

Social-emotional health

A written feedback form was used to collect social-emotional health reflections, in relation to the program goals of connectedness and sharing experiences in the program at the music therapy program's conclusion. Clients and staff were asked for their opinions about outcomes, good and bad features of the sessions, and general comments. Assistance from staff other than the music therapy student was available for clients who chose to dictate their response, otherwise clients completed the form independently. Seven participants completed this form. As participants had the option of being anonymous, it's not clear how many of these responses came from clients or staff, but given the choice to identify themselves, responses came from at least one staff member and three clients.

Responses to qualitative questions were analysed using thematic analysis. Themes about what clients gained from the program were relaxation ("good relaxation strategies"), connection to each other's music ("a variety of diverse music and people's connection to that music"), introduction to instruments, friends ("the friends + laughter + company"), enjoyment ("good laughter ... fun, happy times"), singing and brainstorming lyrics. In response to the question about program outcomes, participants' discussed aspects of the music therapy process and activities/interventions used in the program. The inclusion of this tangential information, as well as general repetition in responses to questions, suggested that there may have been misunderstanding in the specific topic of each question, or overlap in what clients gained in the program and what they thought was good in the program.

Program evaluation

Of the seven respondents, three thought the program was "good" and three thought it was "really good", with one person not providing a response. All seven respondents said they would like to see a similar program in future. Themes for the "good" parts of the program were relaxation, singing, all of the program, the company ("coming together as a group and working with each other"), memory games, song development, breaking down barriers ("music breaks down barriers"), and easing burdens ("music makes us smile, ease our own burdens of our chests"). Themes for "bad" parts of the program were that there were none, improved session rules, and a want for more country and Aboriginal and Torres Strait Islander music. Two of the group elders who identified themselves on these questionnaires provided comments in this section emphasising how much they enjoyed the program, which is of importance due to the respected role of authority elders hold in Aboriginal and Torres Strait Islander communities (Thompson, van der Berg, & Smith, 2011).

New knowledge

What does this tell us about cultural safety in this program?

As explained earlier, cultural safety exists when clients are able to evaluate the effectiveness of services for them through their own cultural lens and this perspective is valued. Establishing if this has been achieved in the pilot program, however, occurs through more than just examining clients' feedback, but in also reflecting on whether clients felt safe to provide honest feedback, and through ensuring that the program and its outcomes are viewed through a culturally appropriate lens.

There are a number of aspects of this program that can be seen to contribute to providing a culturally safe service. This pilot program began through an invitation from within an Aboriginal and Torres Strait Islander community-controlled health organisation, which ensured the student was sent where there was a stated community need and desire for music therapy. Goals for the pilot program were developed directly in consultation with clients to ensure they were culturally valued and not lead by the student's own cultural values. Therapeutic techniques were reflected upon and linked to the unique role that music can play supporting in cultural identity, such as the use of music in language from Geoffrey Gurumul, discussion of story and land in song sharing, song as a socio-political voice, use of music in line with oral traditions, and sharing of knowledge from respected community elders (Breen, 1989; S. Thompson et al., 2011; Walker, 2000). In future, a greater proportion of Aboriginal and Torres Strait Islander music and instruments would be beneficial in providing further connection with their cultural identity.

The manner in which program evaluation was carried out also reflected cultural safety. Client feedback was regularly invited and shaped the music therapy program in real-time. Effectiveness was measured against client-set goals, although the music therapist operationalised these goals and decided how they would be measured. While blood pressure could be measured objectively, social connectedness and community health promotion were measured through qualitative client feedback due to a lack of culturally-standardised, culturally safe tools. Client feedback did provide evidence that the music therapy program had supported connectedness for clients within the group. The client goal to share their positive experiences in the program to improve their community health is still being operationalised. The song parody is being recorded and will be shared on an Aboriginal and Torres Strait Islander radio station throughout this year.

What does this mean for Aboriginal and Torres Strait Islander cultural safety in music therapy?

The effectiveness of this program in meeting clients' own needs in a way that valued their culture and identity demonstrates that a music therapy program can operate in a culturally safe manner to support the wellbeing of First Australian people. To expand the prevalence of cultural safety within Australian music therapy, reflections on dominant cultural influences and greater partnerships within music therapy are necessary. For this pilot program, there was divergence from mainstream values, norms and practices. This required the author to reflect on shameful and racist histories, and the uncomfortable acknowledgement of how non-Indigenous therapists have themselves indirectly benefited from this cultural inequality (Hadley, 2013).

In western models of healthcare, clinicians hold power in the relationship because of a value given to expertise and formal education processes and one-way access to personal information (Zur, 2014). Culturally safe services for First Australian adults require the therapist to relinquish this position of power, and redistribute it equally with their client/s. When learning cultural protocols and knowledge, the therapist takes on the position of "learner".

At the core of culturally safe music therapy practice is partnership. Partnering with clients ensures that there can be an open dialogue about the cultural protocols the client values and discussion of any offence caused. This partnership occurs through client-lead goal setting, an understanding of the client's first language and literacy skills, and regular requests for honest feedback. Within music therapy literature, partnership with clients has been discussed as an essential step for sustainable practice and empowerment for clients (Bolger & McFerran, 2013; Thompson, 2014). This discourse also emerges as a priority within the context of Aboriginal and Torres Strait Islander clients accessing music therapy.

Partnering with Aboriginal and Torres Strait Islander communities creates networks which can link the therapist to important community members such as elders, song-owners, or people involved in men and women's business. Community partnerships grow through respectfully consulting community members on areas of expertise, such as gathering information on regional cultural protocols or gaining permission to use traditional songs and instruments.

Partnering with community controlled health organisations supports cultural more broadly. Being in contact with community controlled organisations provides referral networks between culturally-safe services, ensures music therapy services are invited to areas of community-identified need, and supports holistic, multidisciplinary health care underpinned by the same understanding of health. It promotes guidance from Aboriginal or Torres Strait Islander staff members and community liaisons which ensures that all music therapists are situated to learn about these cultures from those within the culture and are supported in developing culturally safe services (Bell, 2013; Zur, 2014).

Conclusion

This music therapy pilot project demonstrated that music therapy can be a culturally safe service when implemented with thoughtful, strategic processes and ongoing reflection. Central to cultural safety, both in this program and for future music therapy programs, is willingness to diverge from dominant western cultural norms, as well as partnering with clients, community and culturally safe organisations. As Aboriginal and Torres Strait Islander culture varies according to region, cultural safety provides a foundational concept to shape how music therapists embark on their learning and working within these unique cultures. By providing a service that First Australian people are safe to engage in, music therapy can play its part in helping address Australia's health inequalities.

I acknowledge the Traditional Owners of the land on which this project took place. I recognise the sacrifice and achievements of Elders and previous generations of Aboriginal and Torres Strait Islander peoples, and the platform they have provided for the development of the pilot program in this article and the continued expansion of Community Controlled Health Services. I also thank all Elders, community members and co-workers who contributed to the writing, reviewing and shaping of this article.

This publication may contain information, names, or references to deceased Aboriginal and Torres Strait Islander peoples that are felt to be culturally sensitive and thus could inadvertently be distressing or offensive.

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Sian Truasheim BA MMusThy, RMT NMT

Institute for Urban Indigenous Health, Brisbane, Queensland, Australia

Email: sianrmt@gmail.com

Table 1.
Summary of Health Conditions of Participants in Music Therapy Program

Group member   Health conditions

Client 1       Coronary artery bypass graft, obstructive sleep apnoea,
               hyperlipidaemia, depression
Client 2       Type 2 diabetes, hypothyroidism, obstructive sleep
               apnoea
Client 3       Asthma
Client 4       Coronary artery bypass graft, multinodular goitre,
               obesity, psoriasis, hypertension, discitis cardiongaly
Client 5       Hypertension, overweight, gout, hearing impairment
Client 6       Diabetes, calcific uremic arteriolopathy, renal disease
Client 7       Asthma, arthritis, depression, controlled hypertension,
               low blood pressure (medication)
Client 8       Diffuse rotor cuff tendinopathy, cerebral atrophy

Note. These group members are a sample of regularly attending
members whose files were accessible to the student at the
time of the program.