Ticking the box of ‘cultural safety’ is not enough: why trauma-informed practice is critical to Indigenous healing

Context

Culturally safe, trauma-informed practice training is essential to achieve cultural safety and healing. For several years, The Seedling Group and other Indigenous organisations have been training government teams, not-for-profit organisations and Aboriginal and Torres Strait Islander communities to work in culturally safe and trauma-informed ways. We have found that understanding the impacts of trauma has the power to enable systems to repair and communities and individuals to heal.

This article examines the origins of cultural safety as a practice for working with Indigenous peoples, demonstrating its flaws and shortcomings. We argue that, without an understanding of the impacts of trauma, ticking the box of cultural safety training is not enough.

Colonisation has inflicted immense damage on the traditional diets, lore, land ownership and ways of living that kept First Nations peoples thriving for more than 50 000 years¹. The violent acts of colonisation, including genocide², have left a devastating legacy³. Historical trauma, collective trauma⁴ and cultural trauma⁵ have broken down the fabric of a once rich and healthy culture. Misguided policies and service-delivery practices are perpetuating systemic racism⁶, and unless we incorporate an understanding of trauma into cultural safety training, we cannot become culturally safe in our practice.

Initiatives to create health and economic equity for Aboriginal and Torres Strait Islander peoples have lacked long-term planning and have proved costly⁷. Governments and policy makers now concede that Aboriginal and Torres Strait Islander peoples must either lead, or be part of the design of, programs that are meant for them⁸ and it is clear that government initiatives must be grounded in trauma-informed principles.

Cultural safety: a short history

The term cultural safety was coined by Māori nurse and scholar Irihapeti Ramsden in the 1990s. Ramsden worked hard to challenge the view that everyone should be cared for in the same way, ‘regardless of who they were’⁹, and eventually the Nursing Council of New Zealand endorsed cultural safety as a requirement for nursing and midwifery education.

Cultural safety was seen as a step beyond cultural awareness and cultural sensitivity. Cultural awareness is acknowledging that someone you are working with has a culture different to yours. Cultural sensitivity is taking steps to understand your own culture and life experiences, and how they impact others. Finally, cultural safety is said to be present when the recipient of your work considers you safe and not a threat to their culture being accepted. To be culturally safe is to understand one’s own culture and the cultures of others without judgement. Only the recipients of care can say if that care is culturally safe¹⁰.

Australian doctor Mary Belfrage learned the meaning of cultural safety in a remote Indigenous community in Alyawarr country north-west of Alice Springs. Belfrage found that ‘people need to feel like themselves and believe that the health care is connected to their lives¹¹ – a clear explanation that can be applied across all disciplines. Belfrage’s cultural awareness emerged from learning about a new culture, and from a deep understanding of the trauma that permeated the community¹¹. We argue that genuine cultural safety must be grounded in a knowledge of trauma and its impacts on individuals, families and communities.

Issues

In Australia, despite three decades of cultural safety training, the gap between Indigenous and non-Indigenous health has widened in many areas¹² and institutional racism continues¹³. 

Those who subscribe to the concept of cultural safety need to recognise and unpack racism that can be interpersonal, covert, overt, institutional or systemic⁶. It is rare for practitioners to reflect on the intergenerational privilege¹⁴ and white privilege¹⁵ that contribute to the equity gap. We argue that closing the gap between knowledge and practice also requires understanding the impacts of trauma and reflecting upon one’s own culture and privilege. A deep knowledge of trauma, combined with critical self-reflection, makes it possible to change belief systems and behaviours. 

Trauma-informed practice asks, ‘What is that person’s story?’ rather than, ‘What is wrong with that person?’ Neurological research supports the view that unresolved trauma resides within the body as physiological memories, leading to distress, discomfort and disassociation when certain triggers are encountered¹⁶. Trauma-informed care reduces the risk of re-traumatisation by being sensitive to individuals’ needs. Trauma-informed care involves trauma screening, building safe working relationships and managing patient disclosure and distress¹⁷. 

An understanding of the Indigenous model of health is necessary to prevent re-traumatisation. This model embraces connection to country, spirit, spirituality, ancestors, culture, community, family, kinship, the physical body, mind and emotions¹⁸. Social and emotional wellbeing is tied to the broader social determinants of poverty, racism, unemployment and lack of safe housing. Trauma related to any of these domains affects the social and emotional wellbeing of Aboriginal and Torres Strait Islander peoples¹⁸. 

Trauma-informed care and practice for Australian Indigenous peoples is not well researched or implemented¹⁷ although we can learn much from important research from Canada³. A recent report highlights the need for trauma-informed care for Aboriginal and Torres Strait Islander peoples, and the need to understand the relationship between cultural competency training and trauma-informed practice¹⁹. Aboriginal psychologist Tracy Westerman links ‘race-based’ trauma to Indigenous suicide, suggesting that trauma has become a central organising principle in the psychological structures of some individuals and communities²⁰. 

While cultural safety training is important, unless we acknowledge the trauma experienced by the developing child, it is difficult to grasp the intergenerational impacts of disadvantage, chronic health outcomes and inequity⁴. The Adverse Childhood Events (ACEs) study found that those who suffered childhood trauma have an increased risk of chronic disease²¹ and re-traumatisation²². 

Individuals whose families have been subjected to wars, residential schooling, stolen generations, oppression and racism can experience intergenerational trauma⁴. Trauma is passed on through generations by disruptions to attachment and the resulting coping strategies³. Atkinson mapped the transmission of trauma through six generations of one Aboriginal family²³. The science of epigenetics now recognises the effect of trauma on gene expression, and it provides us with what is possibly the most detailed explanation to date of the transmission of trauma through the generations²⁴.

Survivors of intergenerational trauma adopt coping mechanisms including addiction, self-harm, suicidal ideation, chronic hypervigilance and hyperarousal²⁵. Complex trauma leads to overrepresentation in care facilities²⁶ and juvenile justice and prison systems²⁷, and it creates barriers to accessing services²⁸. The history of broken family attachment continues today with forced infant removals²⁹.  

Cultural safety training does not address the impacts of intergenerational and other complex traumas. Policy makers and practitioners accept research findings about trauma’s impact on the body, but have so far failed to reform our systems, policies and laws, despite trauma being central to the stories of most individuals who battle mental health disorders and substance abuse³⁰. 

Lessons learned

Trauma-informed practice training delivered through a cultural lens considers Aboriginal and Torres Strait Islander perspectives of health and their experiences of historical and cultural trauma, racism and discrimination. Acknowledging the damage from colonisation and ongoing government policies has given Aboriginal and Torres Strait Islander peoples a foundation to begin healing families and communities. Culturally safe, trauma-informed practice also takes into account Indigenous peoples’ unique strengths and resilience and stories of survival.

Ward et al found that the unsolicited, informal support of peers, Elders and other community groups played a significant role in supporting those with chronic illnesses³¹. They identified a need for more education and knowledge for support groups. Sharing knowledge about trauma has been embraced by these groups, which has led to early identification of trauma conditions, informed support, awareness and empowerment within communities.

The Seedling Group first delivered its training to government departments and non-government organisations. Then we began to get calls from women’s shelters, schools and other grassroots organisations. We have found community to be the most inspiring and rewarding environment in which to deliver our training. Sharing knowledge can have vast ripple effects. One Aboriginal participant shared her knowledge with 22 people in her extended family. This knowledge sharing enabled her to understand her personal and work challenges, and to adopt life-changing coping strategies.

An understanding of trauma tells us it goes against common sense to incarcerate a 10-year-old child or suspend a student for their problematic behaviour. Culturally safe, trauma-informed practice creates a safe space that allows healing to happen. It means hearing the whole story of a person before making a judgement. It is at its most powerful when Indigenous individuals and organisations work towards interrupting their own intergenerational trauma. 

The Seedling Group worked with one such organisation of Stolen Generation men. Their aim was to interrupt the handing down of trauma through their family lines. These men had been stripped of their culture, and told their families had discarded them, or were lost or dead. In a conversation in April 2019, a surviving Uncle revealed that these men were frequently told they were dumb and incapable of learning. Their healing started with sharing and understanding the trauma they had suffered. The benefits of such sharing are beyond profound; they are the very essence of healing our families and communities. 

The Seedling Group’s approach to interrupting intergenerational trauma is to deliver training to those working with First Nations peoples about culturally safe, trauma-informed practice and care through an Indigenous lens. Other Indigenous organisations working towards community recovery from trauma include the Family Wellbeing Program³², We al-li³³, Yarning up on Trauma³⁴, Red Dust Healing³⁵, the Djirruwang Program ³⁶ and many others.

Aboriginal and Torres Strait Islander peoples are beginning to understand the trauma that affects their lives. Reeves suggests that trauma training for survivors can empower them in their healthcare interactions¹⁷. When we carried out trauma training to professionals and community members in one Indigenous community, participants demanded that it be given to teachers at the local school, where children were being punished for things like sleeping during class with their heads on their desks. Staff seemed insensitive to the challenges being faced in the home and community. For community members, knowledge became a tool to demand changes to service delivery in their community.

Conclusion

Cultural safety training has failed Aboriginal and Torres Strait Islander Australians. Now is the time to become trauma-informed, and only that knowledge will allow profound change to the individuals who make up our systems, improving the potential to close the gap between Indigenous and non-Indigenous Australians. We suggest the teaching of cultural safety has become a mere instrument of compliance. To be truly culturally safe is to understand how the history of trauma suffered by Aboriginal and Torres Strait Islander Australians has led to social, emotional and economic disadvantage. What we know about trauma and its effects on the body can greatly influence our journey to becoming culturally safe in our work with all First Nations peoples. Understanding trauma can move us past racist assumptions and help us change our systems and policies. Most importantly, for First Nations peoples, understanding trauma helps us to explore the strengths of our holistic cultures and how we thrived before the injustices of colonisation. 

Acknowledgements

We gratefully acknowledge the Aboriginal and Torres Strait Islander peoples who have contributed to this article by way of their stories, knowledge, learning and resilience despite experiencing deep trauma. We also acknowledge Kath Fisher and Elizabeth Rix for their critical review of this manuscript. We thank Dr Shawn Wilson and Dr Stuart Barlo for their academic and cultural guidance.