Responding to the needs of homeless Aboriginal and Torres Strait Islander young people with complex disability: The Guddi for Young People

Youth homelessness has been identified as a significant problem in Australia, which exposes young people to social exclusion and considerable disadvantage (MacKenzie, Flatau, Steen, & Thielking, 2016). For young people, homelessness increases risks for physical and mental health problems, and negative social outcomes in adulthood including continued homelessnesss, unemployment, and poverty. These problems are further exacerbated for young people with disabilities, particularly amongst Aboriginal and Torres Strait Islander young people. Early intervention is desirable, but a lack of research to guide service provision in relation to the unique needs of Indigenous young people who are homeless has been noted (Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA), 2012; Memmott, Birdsall-Jones, & Greenop, 2012). The purpose of this commentary paper is to examine the complex support needs of homeless Aboriginal and Torres Strait Islander young people with neurocognitive disability (NCD) and to present a service enhancement model – ‘The Guddi for Young People’ – as a culturally and developmentally appropriate response to the needs of this cohort.


Youth homelessness in Australia
In Australia youth homelessness has been identified as a pressing social issue, with 44, 000 young Australians under the age of 25 found to be homeless in the 2011 census (Australian Bureau of Statistics (ABS), 2012).These figures are concerning, and are believed to underestimate actual numbers.Social exclusion and marginalisation are never more acutely felt than for those who are homeless, and people who are homeless at a young age are more likely to experience homelessness repeatedly as adults (Scutella, Johnson, Moschion, Tseng, & Wooden, 2012).Youth homelessness involves immediate and long-term repercussions for individuals, and significant costs to health and criminal justice services (MacKenzie et al., 2016).
Young people who are homeless are at high risk of associated health and social problems.Exposure to violence, drug use, criminal activity, and increased health issues, have been shown to be more prevalent for homeless youth than for the general population, or other marginalised youth who are not homeless (MacKenzie et al., 2016).Over the long term, homelessness can mean significant disadvantage for young people in relation to social and academic development, and future capacity to participate in and contribute to their communities (McGorry, Purcell, Hickie, & Jorm 2007;Slesnick, Zhang, & Brakenhoff, 2017).

Homelessness and Neurocognitive Disability
NCD is believed to be high among homeless populations, and associated chronic illness, mental health, and/or addiction problems create highly complex support needs (Burra, Stergiopoulos, & Rourke, 2009;Spence, Stevens, & Parks, 2004).NCD relates to any disorder of the brain such as acquired brain injury, dementia, impairment related to alcohol and drug use, infections, and Foetal Alcohol Spectrum Disorder (FASD) (Townsend, White, Cullen, Wright, & Zeeman, 2017b).NCD can affect multiple domains including cognitive processes, psychological and physical function, as well as impacting personality and behaviour.People with complex disability are more vulnerable to homelessness than the general population, and are at increased risk of harm when experiencing homelessness (Mackelprang, Harpin, Grubenhoff, & Rivara, 2014).Barriers to social, educational and vocational inclusion experienced by young people who are homeless can be even more intractable in the context of complex disability, particularly when conditions are misunderstood or undiagnosed.

Homeless Aboriginal and Torres Strait Islander young people with complex disability
Aboriginal and Torres Strait Islander Australians are significantly over-represented in disability and homeless populations (Australian Institute of Health and Welfare (AIHW), 2011; Beer, Baker, Mallett, Batterham, Pate & Lester, 2012;Dodson, 2010).They are twice as likely to have a disability, and 15 times more likely to experience homelessness than non-Indigenous people (Homelessness Australia, 2016;Productivity Commission, 2011).Homeless Aboriginal and Torres Strait Islander young people are a highly vulnerable and over represented group amongst homeless young Australians, who are disproportionately exposed to risk factors for poor mental health, substance abuse, suicide, and injury (Azzopardi et al., 2013).Indigenous youth suicide rates in Australia are among the highest in the world (McHugh, Campbell, Chapman, & Balaratnasingam, 2016).Providing equitable access to effective support services should be prioritised.
Although limited, research suggests that many marginalised Indigenous Australians experience complex multiple problems including NCD, FASD, intellectual disability and mental health problems (Massey, Jane, Lindop, & Christian, 2013;Stephens, Cullen, Massey, & Bohanna, 2014;Townsend et al., 2017a).The nature and extent of NCD among homeless Aboriginal and Torres Strait Islander young people is unclear, but is thought to be reflective of the adult population, and therefore likely to be high.Understandings about the needs of homeless youth in Australia are poor.Sub-groups (including Aboriginal and Torres Strait Islander young people) are even less understood, as there is very little Australian research in this area (Kamieniecki, 2001).

Service Gaps
Early intervention to prevent long-term youth homelessness has been identified as a critical policy implication arising from research investigating youth homelessness in Australia (MacKenzie et al., 2016).Although increased housing options are part of the solution, it is vital that the wide-ranging health, social and emotional needs of homeless young people are met.However, current support service frameworks fail to adequately address the complex needs of this cohort, resulting in significant negative consequences.Disability and mental health services specifically catering to the needs of young people who are homeless are rare (Dixon & Lloyd, 2005).The presence of NCD adds complexity, and creates difficulty for services in ascertaining service user need.Workers in the homeless sector report a lack of sufficient supports to respond to the complex needs of homeless young people (Gonzalez & McLoughlin, 2014).Mental health problems and NCD can often be confused, misunderstood, or missed altogether by intake staff, and homeless services typically fail to effectively assess and refer for mental illness and NCD (Gonzalez & McLoughlin, 2014).
In addition to the issues associated with identification of NCD there are further considerations in relation to Aboriginal and Torres Strait Islander young people.Many Aboriginal and Torres Strait Islander adults and young people with mental illness and NCD remain disengaged from mainstream services.Differing concepts and stigma associated with disability and mental illness (First Peoples Disability Network (FPDN), 2013; Ypinazar, Margolis, Haswell-Elkins, & Tsey, 2007); intergenerational experiences of trauma, dislocation and disadvantage (Biddle, 2012;Dodson, 2010;Hunter, 2009); and a mistrust of Government services (Hollinsworth, 2013) contribute to disengagement and disadvantage for this group.

Discussion
An identified lack of culturally safe and culturally informed services and assessment methods contribute to the alienation experienced by Aboriginal and Torres Strait Islander peoples from support services (Barnett & Kendall, 2015;Townsend et al., 2017b).This results in increased levels of undiagnosed or untreated conditions, and contributes to the over representation of Indigenous people in prisons and criminal justice settings (Sotori & Simpson, 2006;Townsend, Hammill, & White, 2015).A lack of understanding about the needs of marginalised Aboriginal and Torres Strait Islander young people increases disadvantage for this cohort in all domains of their lives.'One size fits all' responses to the complexities of this group are ineffective at best, and fail to consider the broad range of needs of homeless youth (Gonzalez, Klendo, & Thorpe, 2013).Holistic, empowering approaches, which recognise and respond to the specific needs of homeless Aboriginal and Torres Strait Islander people, are required (Memmott et al., 2012).It is vital that services acknowledge and understand Indigenous concepts of disability and the impact of trauma; recognise the impact of the past on Aboriginal and Torres Strait Islander peoples' access and engagement with services; and utilise culturally safe and appropriate screening processes which accurately assess cognitive and psychosocial needs (Townsend et al., 2017a).

The Guddi Partnership
The Guddi Partnership has developed a service enhancement model designed to address the service gaps outlined above, and better respond to the needs of homeless Aboriginal and Torres Strait Islander people with complex disabilities.The model was developed by Synapse (The Brain Injury Association of Queensland), Specialist Disability Services Assessment and Outreach Team (SDSAOT), Department of Communities Child Safety and Disability Services Queensland, and Griffith University, for use in an adult population.

The Guddi Protocol for Adults
The Guddi Protocol is a culturally safe tool to assess NCD affecting Aboriginal and Torres Strait Islander people.It is currently utilised in a variety of contexts including homeless services, and Indigenous community services.The Guddi assists services to better understand and appropriately refer Aboriginal and Torres Strait Islander service users experiencing NCD, mental illness and other health issues.The Guddi Protocol consists of culturally safe questions relating to thinking skills, psychosocial functioning, depression, psychosis, and post-traumatic stress disorder (PTSD).Administration of the Guddi is underpinned by a 'yarning' method, which has been described as an Indigenous cultural form of conversation, intended to build trust and relationships (Bessarab & Ng'andu, 2010).
Proper Way Protocols (Somerville, Cullen, McIntyre, Townsend, & Pope, 2017) are embedded into the processes of engaging with Indigenous communities, services, and/or individuals.As such, any business is carried out according to the wishes, values, and customs of the Aboriginal and Torres Strait Islander peoples and communities involved.Engagement has been achieved through developing relationships and trust with various Aboriginal and Torres Strait Islander community health organisations, and ongoing consultation and involvement of people with a disability, Elders and other respected community members.
The Guddi Protocol also involves building service and community capacity to understand and respond more effectively to this cohort.Capacity building in services is achieved through a training component, which includes training in the use of the Guddi, and education about NCD and mental health more broadly.Consultations with Indigenous stakeholders and service providers promote effective partnerships in service provision, and increase knowledge.Industry training and stakeholder engagement activities facilitate greater inter-sectoral collaboration and cross-organisational partnerships, ultimately contributing to more positive outcomes for Indigenous homeless people with complex disability.

The Guddi Protocol for Young People
The Guddi for Young People builds on the Adult Guddi.It aims to strengthen service and community understanding and responsiveness to homeless Aboriginal & Torres Strait Islander young people with complex disability; enhancing social and emotional wellbeing and social inclusion.The Guddi for Young People is multi-faceted, incorporating culturally sensitive and respectful engagement processes; a culturally safe and appropriate assessment protocol; and service and community capacity building.Augmenting the adult model, the Guddi for Young People seeks to include culturally appropriate interventions to provide ongoing support to individuals beyond the identification of complex disability.Of particular interest are interventions that privilege Indigenous ways of knowing and being (Martin & Mirraboopa, 2003), and reflect understanding of the importance of land, culture and spirituality.

Intervention approaches for young people
Outdoor programmes such as Bush Adventure Therapy (with variations such as wilderness therapy, trauma-focused adventure therapy, and outdoor adventure interventions) show promise as a culturally and developmentally appropriate method to engage young Indigenous people, and may be more attractive to young people than conventional interventions (Bruyere, 2002).The centrality of connection to land and 'country' for Aboriginal and Torres Strait Islander identity, and social and emotional wellbeing, is well documented (Ganesharajah, 2009;Zubrick et al., 2014).Bush therapy programmes provide opportunities for reconnecting young Aboriginal and Torres Strait Islander people with the land, community and culture, which is increasingly seen as integral to positive outcomes for this cohort (McDowall, 2016).
Components of bush therapy programmes including connectedness, sharing, and leadership have been identified as important for building resilience for Australian Indigenous people facing hardship and adversity (McLennan, 2015).Australian research has found positive impacts of wilderness therapy on self-concept, social development, behaviour, and clinical measures, and these were maintained over time (Bowen & Neill, 2013).Bush programmes have been shown to improve mental health symptoms, interpersonal relationships, and attachment for young people (Bettmann, Tucker, Behrens, & Vanderloo, 2017), and may be a useful cognitive rehabilitation strategy to address social exclusion, educational disengagement, and behavioural issues (Shanahan, McAllister, & Curtin, 2009).In Australia a number of bush adventure programmes have been developed specifically for Aboriginal and Torres Strait Islander young people, however there is a paucity of research in this area.

Conclusion
The Guddi Partnership offers a model of community and service engagement and capacity building that is underpinned and led by Aboriginal and Torres Strait Islander community values and knowledge.Responding to the needs of homeless Aboriginal and Torres Strait Islander young people with complex disability requires a holistic response which recognises the unique characteristics of this group, and enhances connectedness and understandings between marginalised Indigenous young people and their communities.The key components of the Guddi for Young People which address this need are: utilisation of culturally sensitive engagement processes; development of a culturally informed and appropriate screening protocol to identify NCD and assess physical, mental, and social health domains; and building service and community capacity to better understand and respond to this cohort.Importantly, Guddi for Young People also seeks to incorporate culturally appropriate interventions and supports that enhance social and emotional wellbeing, and reduce the impacts of homelessness to Aboriginal and Torres Strait Islander young people with NCD, their families and communities.More research is needed to further develop evidence-based approaches to engagement and screening protocols, and culturally appropriate interventions specific to Indigenous young people, in order to address the needs of this highly vulnerable group.