Torres Strait healing

1. Introduction

Version followed: Ailan Kastom as defined in Commonwealth law and Torres Strait Regional Authority (TSRA) documents, set within the national Aboriginal and Torres Strait Islander social and emotional wellbeing (SEWB) framework; the psychotherapist's own work follows the DSM-5-TR Cultural Formulation Interview (CFI, APA core version) and its DSM-5 supplementary modules and informant version.

What it is. "Torres Strait healing" is not a single therapy or a manual. It refers to the ways Torres Strait Islander families and communities look after health and wellbeing under Ailan Kastom, which the TSRA's development plan, citing the Aboriginal and Torres Strait Islander Act 2005, defines as "the body of customs, traditions, observances and beliefs" of some or all Torres Strait Islanders, including customs tied to particular persons, areas, objects or relationships [source: https://www.tsra.gov.au/__data/assets/pdf_file/0010/6400/TSDP_2014-18.pdf]. The region's peoples are described by the TSRA as Melanesian in origin, living on eighteen island communities and five Northern Peninsula Area communities on Cape York; the plan names the Kaiwalagal, Maluilgal, Guda Maluiligal, Kulkalgal, Meriam, Kaurareg and Northern Peninsula Area peoples, with Meriam Mir spoken in the Eastern Islands, Kala Lagau Ya or Kala Kawau Ya (dialects of one language) in the other island groups, and Creole and English throughout [source: https://www.tsra.gov.au/__data/assets/pdf_file/0010/6400/TSDP_2014-18.pdf]. A recent nursing and midwifery text notes a shift back to the local name for the region, "Zenadth Kes" [source: Cambridge chapter abstract, see Sources].

Islanders' own health perspectives are holistic: wellbeing is tied to Country (including the sea), kin, tribe and clan, and the chapter abstract describes how traditional medicine practices might be included in Torres Strait primary health care [source: Cambridge chapter abstract]. Public Islander institutional sources describe Ailan Kastom in law, governance, culture and child rearing; they do not publish descriptions of specific healing roles, healers' methods or spiritual causes of illness. This guide therefore does not describe them, and any such description from outside the community should be treated with caution [uncertain]. Healing practice, its knowledge and who may speak about it belong to Islander families and communities.

How change happens, for the psychotherapist. The therapist does not practise Islander healing. Change in the therapist's work comes from culturally safe care that starts from the client's own account of the problem, brings in family and kin as the client wishes, respects Ailan Kastom and the client's chosen cultural supports, and combines clinical and cultural healing in the "best of both worlds" approach associated with the Gayaa Dhuwi (Proud Spirit) Declaration [source: https://www.lowitja.org.au/wp-content/uploads/2023/05/lowitja_consulting_journeys_to_healing_report.pdf] [source: https://www.qmhc.qld.gov.au/awareness-promotion/first-nations-wellbeing/gayaa-dhuwi].

2. Framework

No Islander body publishes a phased clinical protocol for psychotherapists. The phases below are the therapist's own culturally responsive process, built from the CFI, the SEWB model and Islander governance principles [synthesis]. Session counts are suggestions, not source figures [synthesis].

Phase 0. Preparation (before first contact). Goal: know the place, the protocols and the people who can advise. Learn which island group, language and community the client belongs to; identify the service's Aboriginal and Torres Strait Islander health or mental health workers and cultural advisers; learn the service's commitments (for example, the Torres and Cape Hospital and Health Service states commitments to "culturally responsive, community-led health services", Aboriginal and Torres Strait Islander leadership in decision-making and "zero-tolerance" of racism) [source: https://www.torres-cape.health.qld.gov.au/__data/assets/pdf_file/0026/391733/guideline-2615.pdf]. Move on when you know whom to consult and how to reach an Islander worker or adviser.

Phase 1. Engagement and cultural assessment (sessions 1–3, 60–90 minutes; can run in shorter visits) [synthesis]. Goal: a working relationship and the client's own definition of the problem. Use the core CFI (16 questions, four domains) and, where family takes part, the Informant Version; add supplementary modules as needed [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf] [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf]. A precise time for the core CFI is not given by APA; the field trial reports that later interviews took less time [uncertain] [source: https://experts.umn.edu/en/publications/feasibility-acceptability-and-clinical-utility-of-the-cultural-fo/]. Move on when the client's explanatory model, help seeking (including cultural help) and preferences are documented in their words.

Phase 2. Formulation (sessions 2–4) [synthesis]. Goal: a shared understanding across the seven SEWB domains (body; mind and emotions; family and kinship; community; culture; Country; spirituality and ancestors) and their historical, social and political determinants [source: https://www.aihw.gov.au/reports/indigenous-mental-health-suicide-prevention/social-emotional-wellbeing]; a clinical view of whether a mental disorder is present, distinguished from culturally normative experience, with cultural consultation. The CFI informs but is not the only basis for diagnosis [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. Move on when the client (and family, if involved) recognise the formulation as theirs.

Phase 3. Collaborative plan (1–2 sessions) [synthesis]. Goal: a plan that names clinical options and the client's chosen cultural supports side by side, with consent for any contact between them. Move on when the client has agreed the plan, who may be told what, and how the therapist and cultural supports will communicate, if at all.

Phase 4. Treatment and integration (variable; often 6–20 sessions, flexible, family-inclusive, face to face, outreach or telehealth) [synthesis]. Goal: deliver the agreed psychological work while supporting the client's cultural healing and connections; review safety, medicines with the prescriber, and family roles. Move on when goals agreed in Phase 3 are reached or the client chooses to step back.

Phase 5. Review and closure [synthesis]. Goal: review with the client and, if they wish, family; plan how to re-enter care; hand over to local Islander workers or services. Return to Phase 1 if the client's explanation of the problem or circumstances change.

3. Guiding principles

Holistic health. The first of nine SEWB principles listed by AIHW (from the 2004–09 national framework) [source: https://www.aihw.gov.au/reports/indigenous-mental-health-suicide-prevention/social-emotional-wellbeing]. Practical meaning: assess body, family, community, culture, Country and spirit, not symptoms alone.
Self-determination. SEWB principle; the TSRA cultural policy states people's right to decide matters affecting them and to direct how services are delivered on their lands and waters [source: https://www.tsra.gov.au/__data/assets/pdf_file/0006/1779/tsra20cultural20policy20document.pdf]. Practical meaning: the client chooses goals, who is involved and whether cultural supports are contacted.
Cultural understanding and cultural diversity. SEWB principles [source: AIHW, above]; Indigenous peoples "do not constitute one homogenous cultural group" [source: https://researchonline.jcu.edu.au/2313/1/16643_C1_2007.pdf]. Practical meaning: never transfer Aboriginal or another island's practice to this client; ask about their own island, family and church or cultural affiliations.
Follow protocols suited to the specific place and people. The TSRA requires communications and relationships to follow protocols suited to the places, people and practices involved, and to seek community permission and guidance [source: TSRA cultural policy, above]. Practical meaning: ask an Islander worker or adviser how to approach this family before acting.
Ailan Kastom is respected and protected. The TSRA commits to respecting and protecting cultural practices and cultural knowledge; the Meriba Omasker Kaziw Kazipa Act 2020 (Qld) treats information about a practice known to be "of a secret or sacred nature" as confidential [source: TSRA cultural policy] [source: https://www.legislation.qld.gov.au/view/whole/html/inforce/current/act-2020-033]. Practical meaning: do not ask for, record or pass on secret or sacred cultural information; document only what care needs.
Impact of history, trauma, loss, racism and stigma. SEWB principles and determinants [source: AIHW, above]. Practical meaning: name racism and historical harm as real causes of distress, and check how services have treated the client.
Centrality of kinship. SEWB principle [source: AIHW, above]. Practical meaning: ask whom the client counts as family (including cultural parents under Ailan Kastom child rearing) and involve them as the client wishes.
Recognition of strengths. SEWB principle; Gayaa Dhuwi key theme "cultural strength" [source: AIHW, above] [source: https://www.health.gov.au/resources/publications/gayaa-dhuwi-proud-spirit-declaration-framework-and-implementation-plan]. Practical meaning: assess and build on cultural, family and spiritual strengths in every session.
Leadership and presence of Aboriginal and Torres Strait Islander people. Gayaa Dhuwi themes [source: health.gov.au, above]. Practical meaning: work with Islander staff as colleagues with authority on cultural matters, not as interpreters only.
Cultural safety is judged by the client. The Lowitja report frames cultural safety from the patient's perspective [source: Lowitja, above]. Practical meaning: ask the client whether the care feels safe and change it when it does not.
Two-way understanding. Ypinazar et al. call for "two-way understandings" between Indigenous people and Western models of care [source: https://researchonline.jcu.edu.au/2313/1/16643_C1_2007.pdf]. Practical meaning: explain clinical ideas plainly and learn the client's ideas with equal care.
Combine clinical and cultural healing. The Gayaa Dhuwi "best of both world" approach as the Lowitja report describes it [source: Lowitja, above]. Practical meaning: plan both, and never make clinical care conditional on giving up cultural healing, or the reverse.
The therapist stays in role. [synthesis] Practical meaning: never perform, imitate or arrange Islander healing or ceremony yourself; cultural healing is reached through the client's own family and community pathways.
Spiritual explanations are held as the client holds them. [synthesis] Practical meaning: record them as the client's view, neither confirming them as fact nor dismissing them.
Wellbeing and best interests. The main principle of the Meriba Omasker Kaziw Kazipa Act [source: legislation.qld.gov.au, above]. Practical meaning: when culture and safety seem to conflict, safety and the person's wellbeing decide, worked out with Islander advice.

4. Intervention inventory

All interventions below are the psychotherapist's own work alongside Islander families, communities and cultural supports. None of them is Islander healing. Steps are written in this guide's own words; sources are cited per item, and items marked [synthesis] are general good practice not drawn from an Islander source.

4.1 Cultural self-examination and positioning

Purpose: to notice your own assumptions about illness, spirit, family and authority, and the history between your profession and Islander peoples, before they shape the assessment. Use before first contact and whenever a session feels off. [synthesis; principles from AIHW SEWB and Lowitja, see Sources]
Steps: (1) Write down what you believe causes mental illness and what you think about spiritual explanations. (2) Note what you know and do not know about the client's island group, language and history; mark everything that comes from outside sources. (3) Consider how colonisation, racism and past removal of children may shape the client's view of services [source: https://researchonline.jcu.edu.au/2313/1/16643_C1_2007.pdf]. (4) Discuss your position with an Islander colleague or supervisor where possible. (5) Repeat after any rupture.
Example language (illustrative): "I'm not from your island and I don't know your family's ways. I'll ask, and you can tell me what's okay to talk about and what isn't."
Watch for: urges to explain the client's belief away or, the other way, to romanticise it; it is working when you can hold the client's explanation and your clinical view side by side without needing one to win.

4.2 Learning local protocols and who holds authority

Purpose: to approach the client, family and community through the right people. Use in Phase 0 and when a new family or community is involved.
Steps: (1) Identify who holds authority for the matter at hand. Islander sources name several levels: Ailan Kastom as customary lore, with decision-making rights held by Torres Strait Islander, Kaurareg and Aboriginal peoples [source: https://www.tsra.gov.au/__data/assets/pdf_file/0006/1779/tsra20cultural20policy20document.pdf]; Traditional Owners and Prescribed Bodies Corporate for land and sea (20 in the region as of 2013) [source: https://www.tsra.gov.au/__data/assets/pdf_file/0010/6400/TSDP_2014-18.pdf]; families and kin for family matters; and, for the client's healing, whoever the client and family recognise. Who holds authority over specific healing practices is not described in public Islander institutional sources [uncertain]. (2) Ask the service's Aboriginal and Torres Strait Islander health or mental health worker how to approach this family and community. (3) Respect place-specific protocols: the TSRA requires protocols suited to the specific places, people and practices involved [source: TSRA cultural policy]. (4) Record whom you consulted, with the client's consent.
Example language (illustrative): to an Islander colleague: "I'm seeing a young man from one of the eastern islands. Is there anything I should know about how to approach him and his family, and is there anyone you'd suggest I talk to, with his permission?"
Watch for: treating one adviser's view as true for all islands; asking colleagues for secret or sacred knowledge; it is working when families are approached in a way they recognise as respectful and engagement holds.

4.3 Opening the relationship: place, family and kin

Purpose: to start where Islander wellbeing starts (family, kin, Country and sea) and show the client that their connections matter [source: Cambridge chapter abstract; https://www.aihw.gov.au/reports/indigenous-mental-health-suicide-prevention/social-emotional-wellbeing]. Use in the first minutes of the first session and with every new family member.
Steps: (1) Introduce yourself with where you are from and your role, plainly. (2) Invite the client to say where they and their family are from, if they wish. (3) Ask who they want in the room and who they want kept informed. (4) Explain confidentiality and its limits in plain language, including how information moves in small communities. (5) Ask which language they prefer and offer an Islander worker or interpreter (4.11).
Example language (illustrative): "Before we get into why you've come, would you like to tell me a bit about where you're from and who your family are? Only as much as you want."
Watch for: rushing to symptoms; long silences that may be respectful thinking rather than resistance [synthesis]; it is working when the client begins to tell the story in their own order.

4.4 Core Cultural Formulation Interview (DSM-5-TR)

Purpose: to clarify the problem from the client's perspective and that of their social network: meaning, sources of help and expectations of services. It can be used "by any clinician providing services to any individual in any care setting" [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-SectionIII.pdf]. Use in Phase 1 with every Islander client, and again if the picture changes.
Steps: (1) Use the official APA form; clinicians may reproduce it for use with their patients, but modifying or translating it needs APA permission [source: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM-5-TR/APA-DSM5TR-CulturalFormulationInterview.pdf]. (2) Cover the four domains in order: cultural definition of the problem (Q1–3); cultural perceptions of cause, context and support (Q4–10: causes, stressors and supports, role of cultural identity); cultural factors affecting self-coping and past help seeking (Q11–13, including barriers); cultural factors affecting current help seeking (Q14–16: preferences and the clinician–patient relationship, such as perceived racism and language barriers) [source: APA CFI, above]. (3) Use the client's own words for the problem throughout. (4) Note which answers need a supplementary module (4.6). (5) Summarise back and check. (6) Use it to inform, not decide, diagnosis [source: APA CFI].
Example language (illustrative): "Sometimes people describe a problem differently from how doctors or family might. How would you describe what's been happening, in your own words?" and, for the relationship domain, "Is there anything about me, or about this service, that might make it hard to talk openly here?"
Watch for: reading the questions like a form; the client giving the answer they think you want; it is working when the client corrects or adds to your summary.

4.5 CFI Informant Version with family

Purpose: to hear the family's account, since family and kinship are central to Islander wellbeing and families may have carried the problem alone [source: https://researchonline.jcu.edu.au/2313/1/16643_C1_2007.pdf; AIHW SEWB]. Use when the client consents and a relative or friend is involved in care.
Steps: (1) Get the client's consent about whom to interview and what may be shared. (2) Use the Informant Version (17 questions; Q1 covers the informant's relationship with the patient, then the same four domains) [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Informant.pdf]. (3) Interview separately or together, as the client prefers. (4) Compare accounts without ranking them; bring differences back to the client.
Example language (illustrative): "Your son said I could ask you about how things have been. What do you and the family think has been going on for him?"
Watch for: a family member speaking over the client; cultural parents or extended kin who hold real responsibility but are left out (see 4.14); it is working when the family's account adds to the plan rather than overruling the client.

4.6 CFI supplementary modules

Purpose: to go deeper on topics the core CFI flags. APA lists 12 modules: Explanatory Model; Level of Functioning; Social Network; Psychosocial Stressors; Spirituality, Religion, and Moral Traditions; Cultural Identity; Coping and Help-Seeking; Patient-Clinician Relationship; School-Age Children and Adolescents; Older Adults; Immigrants and Refugees; Caregivers. They can be used with the core CFI or alone, at first evaluation, later or repeatedly [source: https://psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview-Supplementary-Modules.pdf].
Steps: (1) Pick modules from the core CFI answers. For Islander clients the most often useful are likely Social Network, Cultural Identity, Spirituality, Religion, and Moral Traditions, Coping and Help-Seeking, and Patient-Clinician Relationship [synthesis]. (2) Use School-Age Children and Adolescents or Older Adults where relevant, and Caregivers with the caregiver, not the patient [source: APA modules, above]. (3) Spread modules over sessions; do not use all at once [synthesis]. (4) In the spirituality module, ask about church, faith and cultural belief as the client frames them, and stop where the client signals the matter is not for outsiders.
Example language (illustrative): "Some people find their faith, their church or their culture helps; for others it's complicated. What part, if any, does that play for you right now?"
Watch for: fatigue; questions that edge into sacred matters; it is working when the module gives you something the plan uses.

4.7 Exploring the explanatory model (Kleinman)

Purpose: to learn what the client calls the problem, what caused it and what treatment they expect, so the plan fits their logic. Kleinman, Eisenberg and Good (1978) set out the questions [source: https://www.cambridge.org/core/product/F99D9D36838A8207D377730DEB445F7B/core-reader]. Use in Phases 1–2; the CFI Explanatory Model module covers the same ground.
Steps: Ask, in your own words and over time: (1) what do you call the problem; (2) what caused it; (3) why did it start when it did; (4) what does it do to you and how does it work; (5) how severe is it, and will it be short or long; (6) what treatment should you receive; (7) what are the main problems it has caused; (8) what do you fear most about it [source: https://tanenbaum.org/wp-content/uploads/2021/06/HANDOUT-Explanatory-Models-of-Illness.pdf]. Record answers verbatim where possible. Expect several explanations at once (for example social, spiritual and medical), and treat that as normal [synthesis].
Example language (illustrative): "What do you think started this? Some people think of things like stress or grog, some think of family trouble or spiritual reasons, some aren't sure. There's no wrong answer here."
Watch for: the client testing whether you will mock a spiritual explanation; Aboriginal studies report causes such as payback for transgressions and malevolent spirits, but those studies did not include Torres Strait Islanders and should not be assumed to apply [source: https://researchonline.jcu.edu.au/2313/1/16643_C1_2007.pdf]; it is working when the client's model visibly shapes the agreed plan.

4.8 SEWB domain mapping

Purpose: to formulate wellbeing in the national Aboriginal and Torres Strait Islander framework. The model (Gee et al. 2014, used in the 2017–2023 national framework) has seven overlapping domains: body; mind and emotions; family and kinship; community; culture; Country ("a living entity"); spirituality and ancestors ("a sense of purpose and meaning"); and it names historical, social and political determinants [source: https://www.aihw.gov.au/reports/indigenous-mental-health-suicide-prevention/social-emotional-wellbeing]. SEWB problems are distinct from mental illness, though they interact [source: AIHW, above]. Use in Phase 2 and at reviews.
Steps: (1) Draw the seven domains with the client (a circle or list). (2) For each, ask what is strong and what is hurting. (3) For Country, include the sea and island; the chapter abstract notes climate change as a threat to Islanders' "physical and spiritual connection to their Country" [source: Cambridge chapter abstract]. (4) Add determinants: racism, history, housing, income, disability. (5) Mark which domains the plan will target and who (clinical or cultural) supports each.
Example language (illustrative): "Let's look at all the parts of life that keep you strong: body, mind, family, community, culture, Country and sea, spirit. Where are you strong right now, and where does it hurt?"
Watch for: filling in the spirituality domain for the client; it is working when the client uses the map to explain change between sessions.

4.9 Asking about cultural healing and other help, without judgement

Purpose: to learn what help the client and family have already sought (family, Elders, church, cultural or traditional healing, clinics) so care can work alongside it. Aboriginal studies report that traditional avenues are often tried first and Western care only after, sometimes at crisis point [source: https://researchonline.jcu.edu.au/2313/1/16643_C1_2007.pdf]; whether the same holds for Islander clients is [uncertain]. Aboriginal and Torres Strait Islander people "have long called for recognition and integration of traditional healers" in mental health [source: https://www.lowitja.org.au/wp-content/uploads/2023/05/lowitja_consulting_journeys_to_healing_report.pdf]. Use in Phase 1 (CFI Q12) and at reviews.
Steps: (1) Normalise: say many families use cultural and clinical help together. (2) Ask open questions about who has helped. (3) Ask what helped, what did not, and whether they want both kinds of help to continue. (4) Do not ask how a healing practice is done, what was said or used; if the client starts to tell you something they then hesitate over, let them stop [synthesis]. (5) Ask whether anything they are taking (including bush medicine or other remedies) should be known to the prescriber, and route that information to the prescriber without advising on it (4.17).
Example language (illustrative): "Lots of families look for help in more than one place: family, church, Elders, cultural ways, the clinic. Who has helped so far? You don't need to tell me anything private about it."
Watch for: the client minimising cultural help because they expect disapproval; it is working when the client mentions cultural supports spontaneously in later sessions.

4.10 Distinguishing culturally normative experience from illness

Purpose: to avoid both pathologising Islander belief and experience and missing a treatable disorder. Use in Phase 2 whenever spiritual experiences, unusual perceptions, trance-like states or sorcery or spirit explanations appear.
Steps: (1) Gather the client's and family's explanation first (4.7). (2) Ask whether the experience is usual or expected in their family, church and community, and whether others with the same beliefs see it as a problem [synthesis]. (3) Apply the diagnostic cultural qualifiers: DSM-5 wording for dissociative identity disorder says identity disruption "may be described in some cultures as an experience of possession" and excludes disturbance that is "a normal part of a broadly accepted cultural or religious practice"; dissociative trance (other specified dissociative disorder) does not apply when the trance is a normal part of accepted collective cultural or religious practice [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]. DSM-5-TR keeps these points in substance; exact wording is [uncertain] [source: https://umsystem.pressbooks.pub/aswbprep/?p=1299]. ICD-11 6B62 trance disorder and 6B63 possession trance disorder require the state to be involuntary and unwanted and not part of accepted cultural or religious practice [source: https://www.findacode.com/icd-11/code-1807490186.html] [source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9199574]. The DSM-5-TR note on culturally sanctioned beliefs and psychotic symptoms is [uncertain]. (4) Look for markers of illness that do not depend on belief content: decline in function, distress the person does not want, sleep loss, disorganisation, risk, substance use [synthesis]. (5) Consult an Islander mental health worker or cultural adviser, with consent. (6) Keep the local clinical picture in mind: a treated-prevalence study in Cape York and the Torres Strait found psychosis in about 0.95% of Torres Strait Islander people aged 15 and over in treatment (higher among Aboriginal people), with alcohol and cannabis judged to have contributed to onset in about half of the whole sample, and the authors flag possible culturally informed misdiagnosis [source: https://www.mja.com.au/journal/2012/196/2/psychosis-indigenous-populations-cape-york-and-torres-strait]. (7) Document both the cultural meaning and the clinical judgement.
Example language (illustrative): "In your family and community, is this something people would see as normal, or as a sign something is wrong?" and "Whatever the cause, the not sleeping and feeling scared all the time sound hard. Can we work on those together while you also get the help your family thinks is right?"
Watch for: relying on belief content alone; deferring entirely to culture when risk is rising; it is working when client, family and adviser accept the assessment and urgent treatment is not delayed.

4.11 Working with Islander health workers, cultural brokers and interpreters

Purpose: to make assessment and care accurate and safe across language and culture, and to put Islander leadership into practice (Gayaa Dhuwi themes of presence and leadership) [source: https://www.health.gov.au/resources/publications/gayaa-dhuwi-proud-spirit-declaration-framework-and-implementation-plan]. Use whenever language, kin relations or cultural meaning are in question.
Steps: (1) Ask the client which language they prefer (Meriam Mir, Kala Lagau Ya or Kala Kawau Ya, Creole or English) [source: https://www.tsra.gov.au/__data/assets/pdf_file/0010/6400/TSDP_2014-18.pdf]. (2) Check with the client whether a proposed worker or interpreter is acceptable, given kin relations and small-community confidentiality [synthesis]. (3) Brief the worker on purpose and confidentiality; agree that they may flag cultural concerns at any time. (4) Debrief after the session. (5) Credit their cultural judgement in records and plans.
Example language (illustrative): "Would you like [worker's role] to join us? If there's any reason that wouldn't feel right, for family or other reasons, just say and we'll find another way."
Watch for: the worker being made a messenger rather than a colleague; relational conflicts the client is too polite to name; it is working when the client speaks more freely with the worker present.

4.12 Collaboration and referral with community-sanctioned cultural supports, when the client wishes

Purpose: to support the client's own pathway to cultural healing, Elders or church and to coordinate with clinical care. National reports call for recognising the role of traditional healers and Elders and implementing NATSILMH's Co-designing Health in Culture recommendation on this [source: Lowitja, above]. The QMHC reports a 2018 Queensland workshop finding that access to "community-based clinical care, cultural healing, and treatment options" improves outcomes [source: https://www.qmhc.qld.gov.au/awareness-promotion/first-nations-wellbeing/gayaa-dhuwi]. Evidence for collaboration comes from other regions: in Nigeria and Ghana, collaborative shared care between traditional and faith healers and primary care (COSIMPO; Gureje et al., The Lancet 2020) reduced psychosis symptoms more than usual care and reduced harmful practices [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306] [source: https://centreforglobalmentalhealth.org/node/839]; in a Ghanaian prayer-camp trial (Ofori-Atta et al., Br J Psychiatry 212(1)), adding psychiatric medication lowered symptoms but did not significantly reduce days in chains [source: https://www.mentalhealthdataprizeafrica.aphrc.org/repository/paper/33405/joining-psychiatric-care-and-faith-healing-in-a-prayer-camp-in-ghana-randomised-trial]. No Torres Strait collaboration programme with traditional healers is described in public sources [uncertain].
Steps: (1) Ask whether the client wants any link between their cultural supports and their clinical care. (2) If yes, let the client and family choose who; never identify or recommend a cultural healer yourself, and never encourage seeking cultural healing outside the client's family and community pathways [synthesis]. (3) Get explicit consent stating what may be shared, with whom and for how long. (4) Make contact through the client, family or an Islander worker, as they prefer. (5) Share only what the plan needs; agree how safety concerns will be raised. (6) Review the arrangement at each plan review.
Example language (illustrative): "Would it help if the people supporting you culturally and I knew what each other was doing? You decide who, and what I'm allowed to say. It's also fine to keep them separate."
Watch for: pressure from family or service for contact the client does not want; advice from any source to stop prescribed medicine (route to the prescriber); it is working when the client experiences both kinds of help as working together.

4.13 Integrating cultural and clinical care in the plan

Purpose: to make the "best of both worlds" approach concrete [source: Lowitja, above]. Use in Phase 3 and at every review.
Steps: (1) List the client's goals in their words. (2) Against each goal, write clinical supports (therapy, medical review, practical help) and cultural supports the client has chosen (family, Elders, church, cultural activity, Country and sea), without describing cultural practices. (3) Note who is responsible for each. (4) Add a safety section (4.18). (5) Give the client a copy in plain language and agree who else may hold one.
Example language (illustrative): "Here's what we've said: you want to sleep and get back out on the water with your uncles. I'll work on the sleep and worry with you; your family and church will keep doing what they do. Does that look right?"
Watch for: the plan becoming a clinical plan with culture added as a footnote; it is working when cultural goals are tracked with the same care as symptom goals.

4.14 Family and kinship work, including Ailan Kastom child rearing

Purpose: to work with the family as the client defines it, which may include cultural parents. Ailan Kastom child rearing practice, recognised by Queensland's Meriba Omasker Kaziw Kazipa (Torres Strait Islander Traditional Child Rearing Practice) Act 2020, is a practice in which a child's birth parents and cultural parents agree to permanently transfer parental rights and responsibility; a Torres Strait Islander Commissioner decides applications for cultural recognition orders, information about the practice known to be "of a secret or sacred nature" is confidential, and decisions must be for the person's wellbeing and best interests [source: https://www.legislation.qld.gov.au/view/whole/html/inforce/current/act-2020-033]. Use whenever family structure, identity or belonging are part of the presenting problem.
Steps: (1) Ask the client who their parents and family are, without assuming biology. (2) If cultural parentage is relevant to identity, grief or belonging, let the client lead; do not treat it as an anomaly or a trauma by default [synthesis]. (3) Do not ask about secret or sacred aspects; record only what is clinically necessary. (4) Include birth and cultural family in meetings only as the client wishes. (5) For legal questions, refer to the Commissioner's office or legal advice; do not advise.
Example language (illustrative): "When you say 'my mum', and 'the mum who had me', I want to make sure I understand who's who for you. Who would you like involved?"
Watch for: imposing Western ideas of adoption loss; it is working when the client feels their family is understood on their terms.

4.15 Grief, loss and connection to Country and sea

Purpose: to support grief and loss in ways that respect Islander connection to Country, sea and kin, and the client's own mourning customs. Use with bereavement, displacement, separation from island, and distress about climate change [source: Cambridge chapter abstract; AIHW SEWB].
Steps: (1) Ask what the client's family and community expect during mourning and how that affects attendance and timing. (2) Adjust sessions around family and community obligations. (3) Ask how to refer to the person who died; follow the client's lead on names and images [synthesis]. (4) Explore loss of connection to island or sea when the client lives away. (5) Do not ask for, or record, ceremony detail.
Example language (illustrative): "Is there anything about how your family does things when someone passes, or what's coming up for the family, that I should know so I can fit around it?"
Watch for: misreading absence during family obligations as non-engagement; it is working when the client feels free to step away and return.

4.16 Historical and intergenerational trauma, racism and service mistrust

Purpose: to address determinants named in the SEWB model (history, racism) [source: https://www.aihw.gov.au/reports/indigenous-mental-health-suicide-prevention/social-emotional-wellbeing] and the fear of services described in Indigenous research [source: https://researchonline.jcu.edu.au/2313/1/16643_C1_2007.pdf]. The Healing Foundation's Four Pillars of Recovery (safety, identity, re-connection, trauma awareness) are presented as principles for healing programmes [source: Lowitja, above]. Use when history, discrimination or past harm in services appear.
Steps: (1) Ask directly about experiences of racism, including in health care (CFI Q16). (2) Validate without defending your profession. (3) Link current symptoms to history and present conditions where the client does. (4) Use the four pillars as a checklist: is the client safe; is identity strengthened; are connections being rebuilt; is the team trauma-aware. (5) Offer trauma-focused therapy only once safety is established and the client chooses it [synthesis].
Example language (illustrative): "Have you or your family been treated badly by services like this one? It matters to how we work together."
Watch for: the client protecting you from criticism; it is working when the client raises a concern about the service and stays.

4.17 Medicines, substances and remedies: routing, not advising

Purpose: to keep the client safe when prescribed medicines, alcohol, cannabis or traditional remedies are involved, without advising on any of them. Alcohol and cannabis were judged to have contributed to psychosis onset in about half of a Cape York and Torres Strait sample [source: https://www.mja.com.au/journal/2012/196/2/psychosis-indigenous-populations-cape-york-and-torres-strait]. Use whenever the client mentions these.
Steps: (1) Ask what the client is taking, including remedies, without judgement. (2) Pass relevant information to the prescriber with consent. (3) Never advise starting, stopping or changing any medicine or remedy. (4) Offer psychological support for alcohol and cannabis use within your competence. (5) If a family or cultural adviser recommends stopping medicine, help the client take that question to the prescriber.
Example language (illustrative): "That's a question for your doctor. Would you like me to let them know you've been thinking about it, so you can talk it through together?"
Watch for: the client stopping medicine quietly; it is working when the prescriber and client discuss changes together.

4.18 Safeguarding and safety planning

Purpose: to protect the client and others while respecting culture. Use in every plan and whenever risk of suicide, self-harm, violence or harm in any setting appears.
Steps: (1) Assess suicide and self-harm risk using your service's standard process; include family and cultural supports in the safety plan as the client wishes, and lethal-means counselling about storage and removal [synthesis]. (2) Know local emergency pathways in remote island settings, including retrieval and telehealth. (3) If any practice, from any source, involves restraint, beating, starvation, sexual abuse, accusations against children, or delay of urgent medical care, follow mandatory reporting and safeguarding law and consult an Islander colleague about how to act safely [synthesis]. (4) Do not assume a cultural practice is harmful, or that harm is cultural.
Example language (illustrative): "When things get really bad, who in your family or community helps you stay safe? Let's put their names in the plan, if that's okay with you."
Watch for: shame about risk; family under strain; it is working when the client uses the plan and the right people are reachable.

4.19 Records and confidentiality of cultural information

Purpose: to protect cultural knowledge and privacy in small communities. The TSRA commits to protecting cultural knowledge and Islanders' "copyright, intellectual property and traditional knowledge" [source: https://www.tsra.gov.au/__data/assets/pdf_file/0010/6400/TSDP_2014-18.pdf]. Use in every record and referral.
Steps: (1) Record the client's explanatory model and chosen cultural supports in their words. (2) Do not record secret or sacred matters, healing methods or names of cultural healers unless the client asks and care needs it [synthesis]. (3) Tell the client what is in their record and who can see it. (4) Check that referral letters carry only what the receiver needs.
Example language (illustrative): "I'll write that your family is supporting you in your own ways, without details. Is that okay?"
Watch for: records that would embarrass the client if read by a relative working in the service; it is working when the client trusts the record.

5. Handling problems

Islander sources do not address most of these situations directly. Unless a source is cited, the guidance is [synthesis].

Fear and avoidance of services. Indigenous research describes fear of Western services, shame, stigma, fear of hospitalisation away from country and of medication affecting family roles [source: https://researchonline.jcu.edu.au/2313/1/16643_C1_2007.pdf] (Aboriginal samples; applicability to Islanders [uncertain]). Response: name the fear, explain what you can and cannot do, offer an Islander worker, outreach or telehealth, and agree small first steps; tell the client plainly when hospital or medication is and is not being considered.
Family coping alone until crisis. Response: invite family early (4.5), explain early signs in plain terms, and agree with the family how they will reach the service before a crisis [synthesis; pattern from Aboriginal studies, source above].
Stuck client (no change). Response: re-run the explanatory model (4.7) and SEWB map (4.8); the plan may be targeting your goals rather than theirs. Ask whether cultural or family matters are unresolved that the client believes must come first, and whether therapy should pause while they do.
"Resistance" that is respect or caution. Silence, agreement without follow-through, or deferring to Elders may be cultural courtesy or caution with an outsider. Response: slow down, ask permission, use an Islander worker, and avoid confrontation.
Non-attendance. Response: check for family or community obligations, mourning, travel between islands, weather, cost and shame before assuming disengagement; offer flexible contact and outreach; never close a file without trying family, with consent, and the Islander worker.
Overwhelm in session. Response: pause, ground in present safety and in what is strong (family, sea, faith as the client names them), shorten the session, and agree what to do between sessions; defer trauma detail until safety is established.
Rupture after a cultural misstep (for example, asking about something not for outsiders, using a wrong name, mixing up islands). Response: acknowledge it plainly, apologise without over-explaining, ask how to put it right, and seek advice from an Islander colleague; record what you learned without recording the sensitive matter.
Client and family disagree about the cause (spiritual, family, medical). Response: hold both explanations in the formulation, look for actions both sides can agree on (sleep, safety, family support), and avoid ruling on whose explanation is right.
Client asks the therapist to deal with a spiritual cause, or to find a healer. Response: say clearly that this is not your role and not something you can do; ask whom in their family, church or community they trust for that; offer to coordinate with their chosen support if they wish (4.12). Do not name or recommend a healer.
Spiritual explanation alongside rising risk or possible psychosis. Response: do not wait for agreement about cause; act on risk, involve the prescriber and crisis pathways, and keep the family and chosen cultural support informed as consented. Frame treatment as treating sleep, fear and safety "whatever the cause" (4.10).
Advice from any source to stop medicine. Response: do not take sides on the medicine; help the client raise it with the prescriber, and with consent let the prescriber know (4.17).
Confidentiality in small, connected communities. Response: ask about kin relations before involving staff or interpreters; agree how you will greet the client in public; limit records (4.19).
Being asked by colleagues or students to explain Islander healing. Response: decline to describe practices you have been told in confidence; refer them to Islander-published sources and Islander colleagues; Ailan Kastom knowledge and its protection belong to Islanders [source: https://www.tsra.gov.au/__data/assets/pdf_file/0006/1779/tsra20cultural20policy20document.pdf].
Concern that a practice is causing harm. Response: assess the actual harm, not the belief; follow mandatory reporting and safeguarding law; involve Islander colleagues in how to act; avoid both ignoring harm as "culture" and treating culture as harm (4.18). Evidence from other regions shows harmful practices can fall when healers and health workers collaborate [source: https://pubannotation.org/docs/sourcedb/PubMed/sourceid/32861306].
Therapist working remotely or flying in. Response: build relationships with local Islander workers first, keep continuity of clinician where possible, and plan handover before leaving.
Cultural parentage, identity and belonging questions. Response: follow the client's lead; refer legal questions to the Meriba Omasker Kaziw Kazipa Commissioner's office or legal advice [source: https://www.legislation.qld.gov.au/view/whole/html/inforce/current/act-2020-033].

Sources

Torres Strait and Australian sources:

TSRA Cultural Policy Document (Torres Strait Regional Authority, February 2011)
Torres Strait Development Plan 2014–2018 (TSRA)
Meriba Omasker Kaziw Kazipa (Torres Strait Islander Traditional Child Rearing Practice) Act 2020 (Qld), current version
Torres and Cape Hospital and Health Service, Applicant Information Pack, TCHHS-WFE-GUIDE-2615, 2025
Drummond A, Mills Y, Mills S, Nona F. Torres Strait Islander health and wellbeing (chapter 4), chapter abstract. In Best O, Fredericks B (eds), Yatdjuligin: Aboriginal and Torres Strait Islander Nursing and Midwifery Care, 3rd edn (2021). Cambridge University Press. Authors, chapter number, edition and year from the publisher's front matter (next item); that the online abstract belongs to the 3rd edition is [uncertain]. (cited as Cambridge chapter abstract)
Best O, Fredericks B (eds) (2021). Yatdjuligin, 3rd edn, front matter and contents (Cambridge University Press)
Ypinazar VA, Margolis SA, Haswell-Elkins M, Tsey K (2007). Indigenous Australians' understandings regarding mental health and disorders. Aust N Z J Psychiatry 41(6):467–478
Hunter EM, Gynther BD, Anderson CJ, et al. (2012). Psychosis in Indigenous populations of Cape York and the Torres Strait. Med J Aust 196(2):133–135
Social and emotional wellbeing (Australian Institute of Health and Welfare)
Gayaa Dhuwi (Proud Spirit) Declaration Framework and Implementation Plan (Australian Government Department of Health)
Gayaa Dhuwi (Queensland Mental Health Commission)
Lowitja Institute (2018). Journeys to Healing and Strong Wellbeing: Final Report, for the National Mental Health Commission

Cultural assessment, diagnosis and collaboration:

Books and papers cited by reference:

Kleinman A, Eisenberg L, Good B (1978). Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 88:251–258.
American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR).
Gee G, Dudgeon P, Schultz C, Hart A, Kelly K (2014). Aboriginal and Torres Strait Islander social and emotional wellbeing. Chapter 4 (from p. 55) in Dudgeon P, Milroy H, Walker R (eds), Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice, 2nd edn. © Commonwealth of Australia 2014; developed by the Telethon Institute for Child Health Research/Kulunga Research Network with the University of Western Australia. Contents and introduction (Telethon Kids Institute)

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