Tujague NA, Ryan KL. Ticking the box of 'cultural safety' is not enough: why trauma-informed practice is critical to Indigenous healing.

The objective of the study was to investigate whether high and low intensity versions of cognitive behaviour therapy (CBT) might be an effective therapeutic approach for enhancing the mental health of Aboriginal Australians. Five university-educated Aboriginal counsellors received in-depth training in CBT. Over the following year, they used CBT strategies with their clients, and met 10 times as a participatory action research group. The group addressed three key questions: (a) Does CBT appear to be useful for Aboriginal Australians? (b) If so, what elements of CBT are perceived to be effective? (c) What adaptations might be made to CBT to enhance its effectiveness with Aboriginal Australians? The resulting qualitative data were transcribed and analysed. Counsellors perceived CBT to be very useful for their Aboriginal clients and for themselves. They reported that it enhanced their clients' well-being, their own clinical skills, and their own well-being, and it reduced burnout. The qualities of CBT that were perceived to be effective were its adaptability, pragmatic here-and-now approach, capacity for low-intensity interventions, safe containing structure, promotion of self-agency, and valuable techniques. It was suggested that the prime requirement for adaptations to CBT were that they would need to fit different social and cultural contexts.

Previous cognitive behavioural therapy (CBT) training studies have suggested that therapists who practice CBT strategies on themselves during training may experience professional and personal benefits. However, it has also been reported that some CBT trainees are reluctant to engage in self-practice. The present study reports an incidental finding from a CBT training study with Aboriginal counsellors: all five counsellors reported that they practiced CBT techniques on themselves without specific encouragement by the trainers to do so. This paper therefore posed three questions: (a) Why-in contrast to some other trainees-did this group choose to apply CBT to themselves? (b) How did they apply it-with what purpose, in what contexts, and which skills? (c) What was the impact of CBT self-practice? Data from the group's reflections were qualitatively analysed by two of the researchers, and "member checked" by the remainder. Results indicated that the counsellors were motivated to practice CBT on themselves for two principal reasons: the value they placed on CBT, and their personal need resulting from the high number of crises experienced while living and working in their communities. The counsellors reported practicing CBT in a wide variety of contexts as part of their learning. As in previous studies, the impact of CBT self-practice was that it increased their confidence and competence as therapists. It also appeared to be a valuable burnout prevention strategy. If the results are generalisable, they suggest that self-experiential training in CBT may be a culturally responsive and adaptive way for Aboriginal counsellors to enhance their learning of CBT skills.

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We appreciate the valuable commentaries that have been provided for our paper "Can CBT be effective for Aboriginal Australians? Perspectives of Aboriginal practitioners trained in CBT." The international authors identify how CBT, with adaptations by culturally responsive practitioners can be of value for non-Western and Indigenous peoples. The commentary by Australian psychologists Dudgeon and Kelly questions the value of CBT for Indigenous Australians, terming it a "Western therapy" that is "culturally unresponsive" and "culturally blind." They also critique the methodology of the study. We argue that CBT can be adapted by culturally competent practitioners to be culturally safe in Australia, as elsewhere. Cultural safety is mostly a function of the therapist, not the therapy. In the Bennett-Levy et al. (2014) study, CBT was delivered in a culturally responsive way by Aboriginal counsellors within their own communities. CBT is a particularly adaptable and versatile therapy, and embodies principles of empowerment and self-determination that are central to Indigenous social and emotional well-being. We are concerned that CBT, which has strong empirical support and has been adapted elsewhere for a range of cultures, including Indigenous cultures, may be being denied to Indigenous Australian clients. There is considerable opportunity to evaluate the effectiveness and versatility of CBT, and variations of its mode of delivery, for all Australians.