NCPIC - National Cannabis Prevention and Information Centre

Bulletin 14: Raising awareness about cannabis, its use and impact on health and wellbeing among Indigenous Australians

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John Howard1, Julia Butt2, Tracey Wright1, Melissa Norberg1, Jan Copeland1, Ted Wilkes2
1National Cannabis Prevention and Information Centre, University of New South Wales, NSW 2052, Australia.
2National Drug Research Institute Curtin University, Perth, Western Australia, Australia.

Introduction

Increasing concern has emerged about the impact of cannabis use on Indigenous Australians and their communities. Approximately one in six respondents to the National Aboriginal and Torres Strait Islander Social Survey (NATSISS) reported they had used cannabis in 2008.1 From the mid 1990s research conducted in small Arnhem Land (Northern Territory, Australia) communities has highlighted alarming rates of cannabis use2,3,4,5 with estimates of past week rates of cannabis use as high as 73 per cent in males and 27 per cent in females.2 In contrast, the 2010 National Drug Strategy Household Survey (NDSHS) showed recent cannabis use in the general Australian population to be 10.3 per cent.6 Data from both Clough et al.’s work and the NATSISS demonstrate that Indigenous women are less likely than Indigenous men to use cannabis; however, it is noteworthy that Indigenous women are substantially more likely to use cannabis than non-Indigenous women. The 2010 NDSHS found that 7.7 per cent of females used cannabis in the previous 12 months,6 whereas the 2008 NATSISS found 11.8 per cent of Indigenous women used cannabis.1 This data originates from two separate data sets which have different sample sizes, participants and possibly models.

Cannabis use has been linked with considerable mental health problems in Indigenous communities.4,5,7 For example, current cannabis users in a remote Aboriginal community in Arnhem Land were four times more likely to report moderate to severe depressive symptoms than non-users.3 Although similar rates of co-occurring depression and cannabis use exist in non-Indigenous individuals,8 the high rates of cannabis use in Indigenous populations raise the possibility of increasing mental health disruption. Currently, mental and behavioural disorders due to cannabis use are the most common principal diagnoses related to substance use for Indigenous Australians, with Indigenous persons being hospitalised for this disorder at almost five times the rate of other Australians.1 In addition, an association between cannabis use and psychotic symptoms has been reported in Aboriginal communities in Arnhem Land.7

Consistent with mainstream Australian use, Indigenous individuals mostly smoke cannabis mixed with tobacco,10,11 and are more likely to smoke tobacco cigarettes and in greater numbers than those who do not use cannabis.12 The physical health burdens associated with combined cannabis and tobacco use are magnified compared to cannabis use alone. Both substances are associated with respiratory, cardiovascular, and dependence problems and tobacco is the leading preventable cause of death amongst Indigenous Australians.13 Interventions need to account for this complexity.11

Social harms arise out of cannabis use for Indigenous Australians. Like alcohol, scarce income is
diverted from food and other necessities to cannabis.2 Furthermore, anecdotal reports suggest
that cannabis use is associated with violence, particularly when supply is limited.14,15

Importantly whilst there is some evidence to suggest that Indigenous Australians use cannabis at higher rates than non-Indigenous Australians,6 there is a lack of comprehensive prevalence data and a lack of data related to the patterns, course and consequences of cannabis use among Indigenous Australians. This lack of knowledge at a national level has made it difficult to prioritise and identify appropriate targets and methods of prevention and intervention.

Contextual factors associated with cannabis use by Indigenous Australians

The higher rates of substance use, including cannabis use, and associated problems among
Indigenous Australians are generally understood in terms of the social disadvantage, exclusion,
and marginalisation experienced by this population.16 Since Australia was colonised in 1788,
Indigenous Australians have experienced genocidal atrocities, displacement, and the large-scale
removal of children from families.17 Social disadvantage persists today and there is undisputed
evidence that the health and social wellbeing of Indigenous Australians is lower than that of the
wider Australian community on a range of indicators including health, employment, incarceration,
housing and education. This social disadvantage occurs against a backdrop of overt and covert
racism against Indigenous Australians which still exists, and operates at a cultural, institutional,
and individual level.17,18,19 These factors are important to consider not only in understanding
prevalence and patterns of cannabis use among Indigenous Australians, but also in developing
appropriate prevention and intervention approaches. These challenges which face Indigenous
communities also impact on the available human and financial resources that can be allocated to
reducing cannabis use.

Prevention and treatment for cannabis use and related difficulties among Indigenous populations

 

There are few examples of effective interventions to reduce cannabis use and related harms. To date, available research on Indigenous populations has tended to focus on describing problems,
case-reports,20,21 and access to mainstream health services.22,23 There is a lack of clear direction for culturally appropriate treatment approaches to cannabis use, very little indication that many Indigenous people seek treatment for cannabis-related issues, and as such very few established treatment approaches for cannabis use in Indigenous communities. It appears that cannabis use may be a neglected topic across Indigenous health, and there may be little community awareness of cannabis use issues. Considering this, a review of health promotion and prevention resources by NCPIC identified few resources that were easily accessible and factually correct. Thus, it appears that we are at the starting point of addressing cannabis use in Indigenous communities. A comprehensive program of cannabis research, resource and intervention development is clearly needed, and needs to be conducted driven by the needs of diverse Indigenous communities and with consideration of the other health factors and priorities which are addressed in overburdened, under-resourced health and education sectors.

What has NCPIC been doing to address cannabis use and related harms among Indigenous Australians?

The National Cannabis Prevention and Information Centre (NCPIC), an Australian Government,
Department of Health and Ageing initiative, is tasked with developing initiatives to reduce the use
of cannabis in Australia by preventing uptake and providing the community with evidence-based
information and interventions. NCPIC has developed a program of work with its consortium partners to address cannabis use with Indigenous communities and to help develop cannabis use as a priority for health and alcohol and other drug service providers and identify opportunities for future work. Some of this work has focused on increasing awareness of potential health and social concerns related to cannabis use, while other work has explored promising approaches to both engaging Indigenous Australians in treatment and the types of treatment interventions available. This work has been guided by engaging with, learning from, and sharing ideas with Indigenous communities. Some of this work is briefly described below, followed by some suggestions for future activities.

Awareness raising project: Artworks, stories and small-grants community projects

NCPIC partnered with seven Indigenous communities to produce a series of artworks that represented communities’ and artists’ beliefs about cannabis and its use. The goal of this project was to raise awareness in the particular communities of cannabis, its use and any associated and undesired consequences. Four of the seven communities produced art by young people. The works tended to reflect how cannabis entered a community, stayed and became problematic. Individuals and groups used the art and brief explanatory stories to promote discussion with individuals or groups, and to develop new stories about courage and change, as some communities have done with alcohol. The ‘styles’ of the art are varied and representative of those of the Torres Strait, eastern coast and Central Australia. A key message from one community was that ‘cannabis was not our culture’. NCPIC, in consultation with participants, used this message when developing the resources. The Cannabis – it's not our culture website (http://notourculture.org.au/) contains the artworks and stories, and downloadable Indigenous-specific factsheets for health care workers.

The two paintings and stories below illustrate the negative impact cannabis has had on some
communities, and the disruption of communities and spirits.

Artist: Amanda McGowan

Community: Nowra, NSW

Story: “Life Force”: “My painting represents the life-force I believe everybody is born with. As it grows it can go two ways. It can flourish or it can wither away. When we flourish we grow healthy and strong and are at peace with ourselves. Or we can go the other way and slowly wither losing our health and the peace that gives us a good life and makes us grow strong. As a mother I know too well how it can affect a whole family and destroy lives. It is hard to watch a child throw his life and health away. Never having money, trying so hard to keep the branches strong so they grow big and strong. If you have ever had one of your branches poisoned then you know how too well it can destroy their growth and prosperity. If as a community we can grow together and show awareness we would flourish. People need people just as plants need water and tender loving care. There
is nothing better than watching your children grow strong and happy, having a good life and spreading their seed growing new life. I hope all plants can grow strong, healthy, happy and spread their seed leaving a good legacy.”

Artist: Barbara Avery, Judy Torrens

Community: Jubullum

Story: “Cannabis came to our community – it had never been part of our culture. It caused conflict, loss of family values, younger children to be neglected, loss of respect towards Elders and other community members, mental illness and sadness. The community was in fear of the anger and depression cannabis was causing. Darkness came over the community as cannabis use increased. The stronger members saw the effects on individuals and knew that path was wrong. With their strength and leadership, with their knowledge of family and culture, guidance and support is being given to those affected by drug use. The darkness is being lifted and the community is moving forward to a brighter future. Drugs will not ruin our life, our community, it is not our culture!”

Following on from the artwork project, and to enable continuity of involvement between NCPIC and communities, a small grants scheme was developed to assist communities to further ideas that developed out of the artwork project. This small grants scheme has enabled some the communities involved in the project to take ownership of and drive solutions to cannabis-related issues in their communities. Activities NCPIC funded included branding football jerseys with logos (‘Yukiri Wanti’, Leave it! Gunja), sports carnivals, child care workshops, supporting a travelling band who wrote songs that deal with healthy lifestyles, cannabis use and related issues, further art projects, a pre-school revamp, and ‘bush runs’ to gather raw materials for Indigenous art projects.

An addition to the NCPIC activity was the work of Indigenous inmates at Silverwater Correctional Centre who developed posters and stories which represent their reflections on how cannabis has affected their lives. See:
http://ncpic.org.au/workforce/criminal-justice/cannabis-conference/indigenous-posters/

Awareness raising project: Aboriginal and Torres Strait Islander Music Competition

NCPIC has an annual national Aboriginal and Torres Strait Islander Music Competition that is open to all Indigenous Australians. The competition was the result of discussions with Indigenous communities about the effects of cannabis use on their communities and the identified need to increase awareness about the negative effects of cannabis use. The winner receives a studio recording and has their music placed on the NCPIC website and available for download: http://ncpic.org.au/indigenous/projects/. Each year NCPIC produces a CD of the finalists’ songs and sends it out via the website’s online order form free of charge.

The Cully Kids of Cunnamulla song, ‘Wanna-Bees’, won the 2010 Music Competition Runner Up prize. The chorus of their entry demonstrates their view of the impact of cannabis on their community, and how family and community members need to care more about each other:

People smoke marijuana to be a wanna-be

They have a backyard full of yarndi trees

But you see I wanna be the deadliest I can be

That’s why I go to school to learn my ABCs

So freeze! Now rewind it back please

You need to live your life while you're young and free

So please! You gotta listen to me

While I’m talking to my young black Aborigines

So all my Murris in the hood I got a message for you

Think about your family whatever you do

Look out for your sister, brother, uncles and aunties

And your mum and your dad, don't worry about the yarndi

Summary

Both awareness raising projects, the Artwork Project and the Music Project, were able to achieve successful outcomes in four areas. Firstly, they served to raise the awareness of cannabis-related harms in the communities which participated. Secondly, they resulted in the development of community-driven health promotion resources which are now readily accessible using the NCPIC website. Thirdly, these projects resulted in collaborative relationships between NCPIC and participating communities which have enabled capacity-building in both NCPIC and in Aboriginal communities. Finally, the content of these projects provides insight into areas of concern for communities. This information can now be used to further develop interventions which are targeted at areas of community priority.

Other awareness raising projects: Weed it Out

A unique partnership was formed between Queensland Police, James Cook University (JCU) and peak bodies of remote Indigenous communities, including elected local government members, to reduce cannabis-related harms in Cape York and Torres Strait in Far North Queensland. One of its aims is to raise community awareness and provide education programs that are targeted to influence community attitudes towards cannabis use. In collaboration with JCU, research into patterns of cannabis use data has been collated, and the findings are presented back to community members in a culturally appropriate manner. Capacity-building efforts in these communities have proven instrumental for the implementation of supply reduction and crime prevention strategies. NCPIC has assisted in delivery of community awareness activities in the communities, and, in line with the new NCPIC Cannabis and Sport Don’t Mix resources, the Weed it Out project has also formed partnerships with AFL, QRL and NQ Cowboys to promote healthy lifestyle choices. To ensure proposed strategies are community-owned and supported, an intensive six-month police-funded community and key stakeholder consultation phase was undertaken.

Based on a model of ongoing community engagement, the Weed it Out project provides community-based interventions featuring demand-reduction initiatives, over a four-year period, alongside targeted policing efforts to reduce cannabis availability and use in Cape York and Torres Strait communities. The project was extended recently to Charleville in the south-west of Queensland with NCPIC again providing awareness and information activities for communities, young people and parents, and health and allied health workers.

Strategies include:

  • raising awareness of the widespread use of cannabis and its mental health effects
  • providing ongoing feedback about research findings to each community
  • providing information about the legal aspects of cannabis use and trafficking

Themes from community consultations in 16 communities across Cape York and the Torres Strait region are presented over the page.

Other awareness-raising projects: Yindyamarra: ‘Young Men and Yarndi’ youth camp with Lithgow students

With the Lithgow Information and Neighbourhood Centre (LINC) and local Indigenous elders, NCPIC supported and co-developed a camp for young Indigenous men who may or may not be using cannabis. The three-day camp provided seven students aged 12-15 who identified as Aboriginal with education on culture, health and lifestyle, and cannabis-related issues. The camp had an emphasis on healthy physical activities as well as periods of information sharing and knowledge clarification and acquisition, utilising a variety of media – for example, art and music. The hope was that once the young men returned to their families, peer groups and communities they would feel capable of sharing what they had learned, and this appears to have been the case via the follow-up with participants to ascertain the extent of their sharing the main health-related messages from the camp with their peers.

There was no prerequisite that camp participants use cannabis, but all, whether using cannabis or not, had family, neighbours or peers who used cannabis – some heavily.

The activities aimed to:

  1. raise awareness of cannabis as an issue for young Indigenous Australians
  2. clarify existing knowledge and beliefs
  3. provide accurate information
  4. raise awareness of harm reduction so that information can be shared with peers who may being using cannabis
  5. create healthy messages than can be diffused among family and peers, and
  6. encourage helpseeking if difficulties are experienced.

Session 1: What do you know about cannabis? Separating fact from fiction!
  • brainstorming what is already known, a quiz and information clarification.
Session 2: Helpful messages for mates/mob
  • use of NCPIC posters to provoke discussion about and development of helpful messages that could be promoted by participants among their peers.
Session 3: Reducing harms
  • use of Indigenous music competition winners to provoke discussion about harm reduction messages.

Primary health care project: Could it be the gunja?

NCPIC consortium partner, the National Drug Research Institute (NDRI) has been working in collaboration with six Aboriginal Community Controlled Health Organisations to develop culturally safe cannabis intervention approaches at a primary health care level as part of the Could it be the gunja? project (also called Could it be the yarndi?) at several sites. The Could it be the gunja? project was initially a five stage project, the five stages were: consultation and collaborative project definition, intervention development, intervention pilot, review of outcomes and finally to re-pilot.

In the consultation and project development stage it was identified that few staff regularly talk to clients about cannabis, further, many staff reported not feeling comfortable talking about cannabis, yet despite this many staff felt that cannabis use was having a significant effect on the local community. Consequently the goal of the project was to start at the beginning by introducing screening and brief intervention for cannabis use, and cannabis information resources to primary health care clients. Most importantly the project developed a comprehensive implementation plan to ensure that the introduction of screening and brief intervention went beyond a training only model. The development of the screening and brief intervention content and structure and the resources was collaborative. In line with consultation feedback that communities are tired of ‘no’ messages, the program aimed to provide information about cannabis in an open and informative way. The project was initially piloted with four Indigenous community-controlled health organisations. Following this, the pilot outcomes were reviewed and adjustments made to the resources, screening, brief intervention and the implementation process. The project was then re-piloted with a further two community-controlled health services.

As an example of outcomes; before the project started only 20 per cent of clinic staff (including nurses, GPs and health workers) regularly talked to clients about cannabis, but at the end of the project 60 per cent of participants were talking to their clients about cannabis use. In addition, at the end of the project participants felt more comfortable asking about cannabis and felt that they knew more about cannabis and had the skills to help people who use cannabis. From the success of the project, NDRI, its partners in Indigenous community control and NCPIC are working on a dissemination program.

MAKINGtheLINK

MAKINGtheLINK: Promoting Helpseeking for Drug Use and Mental Health Issues Among Aboriginal and Torres Strait Islander School Students, is an educational resource that includes activities for school-aged students to encourage them to seek help for problems related to cannabis and other drug use and mental health. By seeking help early, young people are less likely to develop long-term problems as a result of emerging mental health and drug use issues. Young people are often reluctant to seek help from professionals and tend to keep their problems to themselves or turn to friends, parents or teachers for support – people who often don't know what to do. This activity-based learning resource uses kinaesthetic, visual and auditory learning methods, and is a resource developed with the target population and thus, hopefully, culturally appropriate and relevant to their needs.

Ways forward?

As described above, in NCPIC's short history it has begun to develop collaborative relationships and priorities for cannabis intervention with Indigenous communities Australia-wide. To date the projects undertaken represent a starting point in addressing cannabis use. The next steps clearly need to move beyond health promotion and awareness raising and continue to build on workforce development, early intervention and treatment development. To help achieve these outcomes NCPIC has convened the NCPIC Aboriginal and Torres Strait Islander Reference Group to guide the development of projects aimed toward Indigenous cannabis use and cannabis-related harms. In addition, NCPIC is committed to collaborations with Indigenous individuals and organisations in the areas of workforce development, treatment development, and community-led initiatives.

Opportunities for workforce development in relation to awareness raising and early intervention are an ongoing priority for NCPIC across the full breadth of its program of work. By engaging in capacity-building, ongoing workforce development through such projects as Could it be the gunja?, Indigenous MAKINGtheLINK, and the camps for young people, it is hoped that NCPIC can contribute to building the Indigenous health and education workforce so that it is sufficiently resourced in both skills and materials to address cannabis use at regional, community and individual levels. In projects such as these, ongoing relationships with Indigenous organisations can ensure the ownership of projects remains within Indigenous communities and enhance opportunities for success. The support and control of local communities is a recognised facilitator of successful alcohol and other drug interventions.24

A significant upcoming challenge is also the development of culturally appropriate treatment responses to cannabis use and cannabis-related harms. Regardless of how treatment is approached from a theoretical standpoint, it remains the case that the needs of Indigenous Australians are complex in nature.25,26 NCPIC has been exploring an approach that draws on both the Narrative and Cognitive Behavioural (CBT) therapies. A treatment approach that draws on Narrative therapy may be useful as it considers the broader social contexts of people’s lives.27 While not uncontested, the Narrative approach has been used with populations marginalised by such factors as race, class, psychiatric diagnosis, sexual orientation, and gender.28 Narrative therapy looks at the many narratives (stories) operating in one’s life or community and aims to identify unhelpful narratives, understand them and uncover alternative stories. Such an approach
could be relevant to issues of disempowerment, which are consistent themes in understanding Indigenous alcohol and other drug use. The telling of alternative and more positive stories by people from marginalised backgrounds can illustrate that change is possible and achievable.29 An additional value of Narrative therapy may also lie in its focus in identifying how a community has been dealing with the problem to date.30 However, as cautioned by Gray and Wilkes31, interventions such as Narrative therapy, developed in non-Indigenous populations, cannot simply be imposed on Indigenous communities. To be effective, Narrative therapy needs to be adapted to local cultures and be subject to Indigenous community control.31

NCPIC recognises that there is much work ahead, and is committed to working with Indigenous communities and Indigenous organisations to raise awareness of cannabis, its use and associated harms to health and wellbeing. NCPIC is also committed to assisting in developing intervention and treatment responses consistent with best available practise in Indigenous alcohol and other drug intervention. The future work undertaken will focus on the priorities developed through the NCPIC Aboriginal and Torres Strait Islander Reference Group and will maintain a focus on culturally appropriate capacity-building, community engagement and community control.

References

  1. Australian Institute of Health and Welfare. (2011a). Substance use among Aboriginal and Torres Strait Islander people. Cat. no. IHW 40. Canberra: AIHW.
  2. Clough, A., D’Abbs, P., Cairney, S., Gray, D., Maruff. P., Parker, R., & O’Reilly, B. (2004). Emerging patterns of cannabis and other substance use in Aboriginal communities in Arnhem Land, NT. Drug and Alcohol Review 23, 381-390.
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  12. NSW Department of Health. (2010). The NSW SmokeCheck Aboriginal tobacco prevention project. Sydney: NSW Department of Health.
  13. Penm, E. (2008). Cardiovascular disease and its associated risk factors in Aboriginal and Torres Strait Islander peoples. Canberra: Australian Institute for Health and Welfare.
  14. Select Committee on Substance Abuse in the Community. (2007). Substance abuse in remote communities: Confronting the confusion and disconnection. Darwin: Legislative Assembly of the Northern Territory. Available from: http://www.nt.gov.au/lant/parliamentary-business/committees/substance/Substance%20Abuse%20 Report%20CONTENT.pdf
  15. Wild, R. & Anderson, P. (2007). Ampe akelyernemane meke mekarle: Little children are sacred, Report of the Northern Territory Board of Inquiry into the Protection of Aboriginal Children from Sexual Abuse. Darwin: Northern Territory Government. Available from: http://www.inquirysaac.nt.gov.au/pdf/bipacsa_final_report.pdf
  16. Gray, D. & Saggers, S. (2002). Indigenous Australian alcohol and other drug issues: Research from the National Drug Research Institute. Perth: National Drug Research Institute, Curtin University of Technology.
  17. Dudgeon, P., Wright, M., Paradies, Y., Garvey, D., & Walker, I. (2010). The social, cultural and historical context of Aboriginal and Torres Strait Islander Australians. In P. Purdie & R. Walker (Eds.), Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice. Canberra: Commonwealth of Australia.
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  19. Paradies, Y., Harris, R. & Anderson, I. (2008). The impact of racism on Indigenous health in Australia and Aotearoa: Towards a research agenda. Darwin: Cooperative Research Centre for Aboriginal Health.
  20. Paul, C., Sanson-Fisher, R., Stewart, J., & Anderson, A. (2010). Being sorry is not enough: The sorry state of the evidence base for improving the health of Indigenous populations. American Journal of Preventive Medicine 38, 566-568.
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  22. Andrews, B., Simmons, P., Long, I., & Wilson, R. (1999). Identifying and overcoming the barriers to Aboriginal access to general practitioner services in rural New South Wales. Australian Journal of Rural Health 7, 229-236.
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  27. Morgan, A. (2000). Externalising conversations: Naming the problem: What is narrative therapy? Adelaide: Dulwich Centre Publications.
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  30. Denborough, D., Koolmatrie, C., Mununggirritj, D., Marika, D., Dhurrkay, W., & Yunupingu, M. (2006). Linking stories and initiatives: A narrative approach to working with the skills and knowledge of communities. The International Journal of Narrative Therapy and Community Work 2, 19-51.
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Additional useful references:

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  3. Australian Indigenous HealthInfoNet. (2009). Summary of Australian Indigenous health, 2009.
  4. Bacon, V. (2007). What potential might Narrative Therapy have to assist Indigenous Australians reduce substance misuse? Australian Aboriginal Studies 1, 71-82.
  5. Beels, C. (2009). Some historical conditions of narrative work. Family Process 48, 363-378.
  6. Benson-Stott, E. (2008). Mental unwholeness: Working with Aboriginal and Torres Strait Islander people. The Professional Counsellor 4, 8-16.
  7. Burgess, C., Johnston, F., Berry, H., McDonnell, J., Yibarbuk, D., Gunabarra, C., Mileran, A., & Bailie, R. (2009). Healthy country, healthy people: The relationship between Indigenous health status and “caring for country”. Medical Journal of Australia 190, 567-572.
  8. Centre for Rural and Remote Mental Health. (2009). Key directions for a social, emotional, cultural and spiritual wellbeing population health framework for Aboriginal and Torres Strait Islander Australians in Queensland. Centre for Rural and Remote Health Queensland. Available: http://www.crrmhq.com.au/pdfs/CRRMHQ%20SESWB%20Report%20for%20web.pdf
  9. Cheung, F. (2000). Deconstructing counseling in a cultural context. The Counseling Psychologist 28, 123-132.
  10. Close The Gap. (2008). Indigenous Health Equality Summit. Statement of intent. Retrieved from http://www.hreoc.gov.au/social_justice/health/statement_intent.html
  11. Copeland, J., Swift, W., Roffman, R., & Stephens, R. (2001). A randomised controlled trial of brief interventions for cannabis use disorder. Journal of Substance Abuse Treatment 21, 55-64.
  12. Copeland, J. & Swift, W. (2009). Cannabis use disorder: Epidemiology and management. International Review of Psychiatry 21, 96-103.
  13. Davidson, G., Sanson, A. & Gridley, H. (2000). Australian psychology and Australia's indigenous people: Existing and emerging narratives. Australian Psychologist 35, 92-99.
  14. Denborough, D., Wingard, B. & White, C. (2009). Creating storylines: What is it about these stories that ‘make spirits strong’? Yia Marra. Adelaide: Dulwich Centre Foundation & General Practice Network NT.
  15. Drug and Alcohol Office Government of Western Australia. (2005). ‘Strong Spirit, Strong Mind’: Western Australian Aboriginal Alcohol and Other Drugs Plan 2005-2009. Perth: Government of Western Australia.
  16. Flegg, K., Phillips, C., Collins, A.L., Sharp, P., Kanagasundaram, M., Lovett, R., & Kljakovic, M. (2010). Health service attendance patterns in an urban Aboriginal health service. Medical Journal of Australia 193, 146-148.
  17. Gray, D., Haines, B. & Watts, S. (2004). Alcohol and other drug education and training for Indigenous workers: A literature review: Aboriginal Drug and Alcohol Council (SA) Inc., & National Drug Research Institute, Curtin University of Technology.
  18. Gray, D., Jackson Pulver, L., Saggers, S., & Waldon, J. (2006). Addressing indigenous substance misuse and related harms. Drug and Alcohol Review 25, 183-188.
  19. Hoy, W. (2009). “Closing the gap” by 2030: Aspiration versus reality in Indigenous health. Medical Journal of Australia 190, 542-544.
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  22. Larner, G. (2004). The flipside of sixpence: Aboriginal stories of hope and reconciliation. Australian and New Zealand Journal of Family Therapy 25, 37-44.
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  24. Mackean, T. (2009). A healed and healthy country: Understanding healing for Indigenous Australians. Medical Journal of Australia 190, 522-523.
  25. McDermott, D. (2006a). Growing up brown in a white-shirted time. Medical Journal of Australia 185, 464-466.
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