The eight priorities of the
strategy provided the starting point of discussion for
MDAA's consultation process.
7.1 Providing information on
mental health services to people of culturally and
linguistically diverse backgrounds in a manner that is
sensitive to their cultural values, practices and
language.
Information on mental health and
mental health services to people from a NESB is at best
limited. The information available is usually very basic.
The few materials that are available are generally
pitched at community education level. Very little is
available in some level of detail about specific
conditions for people with mental illness and their
families.
Not only is much of the information
only available in English, almost all of the images used
in the materials are images of
Anglo-Australians.
Much of the information appears to
have been simply translated with no regard to getting the
information across in a culturally sensitive manner. For
example, whilst a term such as depression is increasingly
acceptable in Western communities, it is not a term used
in many communities, who might prefer 'sadness or
melancholia' as descriptors.
The information that is available
is usually available for the large, established language
communities, while new and emerging communities do not
have access to written information. The translated
information is usually not made available in hard copy,
but through web- based information, placing the onus on
the person or their family to find and print out the
material and/ or shifting the printing and copying costs
onto community organisations and local mental health
services.
For a person and their family whose
main language is not English, getting information is
largely based on the premise that the consumer and their
family will be proactive in seeking out the information.
It is hard enough for anyone to access information when
they are well, but when in crisis, the limited
availability of information in the language spoken often
exacerbates the sense of crisis.
Much money is wasted by
'forgetting' to link the information production side with
the dissemination side and mostly there are no strategies
for how to disseminate any information in the different
communities. GPs and (largely private) psychiatrists who
are key access points for people from a NESB do not know
or simply do not distribute the information.
Translated materials, taken
directly from the English language version without taking
into account cultural contexts do not meet the mental
health information needs of people from a NESB. This is
particularly the case for refugees who are survivors of
torture and trauma: information needs to be readily
available about the specificity of their experiences and
conditions.
Finally, there is an over-emphasis
on written information for NESB communities, which does
not take into account the low levels of literacy amongst
many NESB communities.
7.2 Facilitating better
co-ordination between mental health services and
multicultural services to improve access and care to
mental health services by people from culturally and
linguistically diverse backgrounds.
Some services such as the Service
for the Treatment and Rehabilitation of Torture and
Trauma Survivors (STARTTS, which is funded in part by the
NSW Government) and the NSW Transcultural Mental Health
Centre (TMHC, which is fully funded by the NSW
Government) have strong links to multicultural community
services. These services employ bicultural/bilingual
counsellors who serve in many different communities.
However, these two services, as well as multicultural
community-run services do not have the capacity to deal
with the demand.
The problem facing people from a
NESB is that if they want to use a service with a high
level of cultural competency, they have to wait longer
than their Anglo-Australian counterparts, as those
services are stretched beyond capacities. Alternatively
NESB consumers may want to try to access 'mainstream
services' with little or no connections with NESB
communities and low levels of cultural competencies,
which may mean the consumers lack confidence in the
quality of those services.
Exacerbating the situation is the
persistent impression amongst mental health service
providers that the responsibility for people from a NESB
with mental illness lies with NESB communities. An
attitude of 'they look after their own' is not only
simply wrong, it also does not take into account the
levels of stigma surrounding mental illness and the low
levels of resources amongst NESB communities.
7.3 Enhancing the skills and
capacity of mental health professionals to enable them to
provide timely, appropriate and effective mental health
services to a culturally diverse
community.
As discussed above, people from a
NESB have a significantly lower mental health service
utilisation rate than their Anglo-Australian counterparts
(TMHC submission, p.4). A number of researchers indicate
that this under-utilisation is not the result of the
lower occurrence of mental illness amongst people from
NESB communities, but rather it is based on the existence
of various barriers to accessing services and inequities
of appropriate mental disorder assessments (TMHC
submission, p.11).
One of the key barriers to equity
in mental health services is the overall low levels of
cultural competencies amongst mental health care
professionals. It is clear from MDAA's consultation and
our advocacy work that a significant shift towards
understanding of cultural diversity needs to occur. It is
increasingly clear that mental health practices in a
culturally diverse community such as NSW need to be
transcultural mental health practices. There simply is no
'good' mental health without transcultural mental health.
For example, unless the practitioner has knowledge and an
understanding of the particular cultural background of a
client and how that culture inscribes (not clear what you
mean by inscribes in this context - do you mean ascribes/
attributes meaning to?) practices and behaviours, the
practitioner will be unlikely to assess and diagnose
appropriately. A 'one size fits all' approach will
increasingly not meet the needs of the diverse community
in NSW.
Another key barrier is access to
and use of interpreters. MDAA clients' experiences
indicate that health interpreting services are not
readily available. For the purpose of this submission,
statistical data on health interpreter use for mental
health purposes has been obtained from four Area Health
Services (three Sydney based and one regional). However,
it is impossible to compare the data obtained, as
classifications and methods of data collection vary
across all the health areas. For example, some area
health services record data on health interpreting
services in general, while others maintain separate data
for interpreting in different health settings, such as
early childhood, mental health, palliative care, etc.
There is no standardised procedure for recording health
care interpreting services and that lack of comprehensive
and reliable statistics across the different area health
services makes any quantitative or qualitative analysis
impossible.
Furthermore, the current model of
mental health care continues to largely disregard other
models of care and non-Western approaches to mental
health. Many of these 'alternative' approaches have been
proven to be most effective and efficient, both in human
and dollar terms, in the provision of good mental health
care. The current over-riding medical model of mental
health care also does not take into account that people
themselves might bring high levels of expertise about
their own health and how to manage their
health.
Frequently 'mainstream' mental
health services respond to people from a NESB who present
with mental health problems, which may or may not be
related to their refugee or migration experiences, by
transferring them to specialist migrant and refugee
services, instead of treating people as part of the
'mainstream'. For example as soon as a person mentions
that they are a refugee, they are referred to a torture
and trauma service, where, most likely, they 'sit' on a
waiting list instead of being treated in a 'mainstream'
setting. This happens irrespective of whether their
mental illness has anything to do with the refugee
experience. In addition, there is an expectation that
non-psychiatric mental health interventions, such as
counselling, skills-oriented training, peer support, etc.
are provided by multicultural organisations. These
services are however, frequently unlikely to have the
resources and the skills to provide such
services.
Finally, from an advocacy agency's
perspective, we are generally appalled about the low
levels of understanding amongst mental health
practitioners about human rights (in relation to the
person's mental health status, and also in relation to
their ethnicity, citizenship status, race, gender, etc.).
(not clear exactly what 'human rights' you are referring
to here - it may help to give an example) Through our
advocacy practice we have encountered prevailing negative
attitudes and stigma and we argue that this negatively
influences the care provided to people from a NESB with
mental illness.
7.4 Increasing the quality and
effectiveness of mental health care in the primary care
setting by enhancing and supporting the role of general
practitioners and primary mental health
carers.
A study of 46,000 people found that
sixty per cent of people visiting their GPs had a mental
disorder. ('Synergy', Australian Transcultural Mental
Health Network, Winter 2001). Research also shows that
74% of mental health care consumers receive their
services from GPs. (Andrews et al., 1994 in TMHC
Submission p. 3). In a study across populations,
involving Anglo-Australians and people from a NESB,
Professor Hickie (currently CEO, Beyond Blue) found that
GPs consistently under-estimate their patients' mental
disorders. In those with severe symptoms, doctors failed
to recognise a problem in more then half the cases. Where
the symptoms were less severe, GPs' recognition of
symptoms of mental illness was even lower. Other research
indicates that people from a NESB use their GPs at
similar rates and show a significant preference for
bilingual GPs who speak their own language. Because
people from a NESB do not have access to the mental
health system, one of the key or only entries into the
health system for people from a NESB is GPs.
The absence of adequate training in
working with NESB consumers coupled with insufficient
knowledge about cultural and other issues (such as past
traumas; process of migration; cultural differences that
may or may not have an impact on mental health) make GP
services insufficient for people from a NESB with mental
illness. GPs are also often reluctant to use clients' own
resources in managing mental disorders. MDAA consumers
report that GPs often use inappropriate terms to describe
mental disorders, often repeating commonly held
stereotypes. The MDAA consultation identified that many
GPs are oriented towards a narrow, traditional perception
of mental illness. 'Minor' mental illnesses such as
depressions, are not being identified. In addition it
appears that the bulk of GPs are focused solely on the
medical model of treatment with counselling, peer support
and other treatment options not being
considered..
Our consultation identified that
some GPs use frontline staff, such as receptionists, to
translate materials or give people explanations on how to
take the prescribed medication. Overall it appears that
GPs do not use interpreters. This leads to wrong
diagnosis, over or under-medication or wrong medication
and other treatments, shorter consultations and overall
poorer clinical outcomes for people from a
NESB.
Being able to communicate with the
client, bilingual GPs can be of benefit to people from a
NESB. However, some concerns have been raised about
attitudinal barriers and knowledge gaps amongst those
GPs. Some of those GPs appear to be providing
'counselling' to people but appear not to have
appropriate training to do so.
7.5 Promoting positive mental
health attitudes and developing strategies for the
prevention of mental health problems and disorders and
providing early intervention to culturally and
linguistically diverse communities.
Mental health literacy amongst NESB
communities does not appear to have increased
significantly over the last 5 years. At MDAA's
consultation the participants had difficulties
identifying initiatives which have been implemented since
the release of the government's strategy.
Except for some initiatives
undertaken by TMHC and STARTTS, promotion practices
continue to be one-off campaigns for a particular target
community group (usually larger and well-established
communities) mostly towards the end of a financial
year.
7.6 Promoting and developing
mental health services which recognise and incorporate
diverse linguistic and cultural needs including
culturally appropriate assessments, diagnosis and
treatment.
Our consultation did not identify
one single so-called 'mainstream' service as a
particularly good (what does 'good' mean here - an
example of best practice that you would like to see
emulated throughout the State?) service. The services
mentioned were those services with a specific mandate to
work with people from a NESB such as STARTTS; Immigrant
Women's Speakout Assoc.; Fairfield Multicultural FPA
(what does FPA stand for - Family Planning Association?);
TMHC; Multicultural HIV Unit; etc.
In relation to particular
population groups, we note that the most crucial point
needing attention is the overall lack of coordination
between agencies and sectors, both within government and
non-government agencies.
In relation to particular groups
within NESB communities and in relation to particular
areas, the consultation revealed the following
issues:
Refugees:
There is a high demand on refugee services in general
and torture and trauma in particular. Whilst additional
resources have been made available to STARTTS, these
additional resources are not enough to deal with the
demand for the service. Serious efforts need to be made
to make 'mainstream' services accessible to refugees and
torture and trauma survivors.
A major area of concern, one which
will become increasingly difficult to address unless
there are significant changes to current policy, is the
ineligibility of Temporary Protection Visa holders to a
whole range of State and Commonwealth funded
services.
Involuntary and forensic
patients:
People from a NESB are over-represented as
involuntary and forensic patients. This highlights that
unless issues of prevention and community education;
access and equity to services, including early
intervention services and access to interpreters are
addressed, people from a NESB will continue to receive
treatments which are severe, more restrictive and less
focused on the prevention of mental illness and the
promotion of good mental health.
In this context, the consultation
and MDAA experience identified that unless a person is
eligible for the Legal Aid funded Mental Health Advocacy
Service, there are no other services available to assist
people when appearing before the Mental Health
Tribunal.
People with dual diagnosis:
Latest research indicates that 25-40% of all people with
an intellectual disability have a mental illness. About
25% of those people will be people from a NESB. Whilst
there is a limited skill base amongst practitioners in
relation to dual diagnosis generally, there is virtually
no skill base in working with people from a NESB with
dual diagnosis. On this issue we refer the Committee to
the recommendation in the submission by the NSW Council
of Intellectual Disability.
Older people:
Other submissions, such as the TMHC's, have
identified the mental health issues of older people from
a NESB as an increasingly significant issue needing to be
dealt with by the mental health system.
Our consultation suggests that the
aged care sector generally knows little about mental
illness, and concerns have been raised about the mental
health of older people from a NESB who have come to
Australia as migrants or refugees. Some of those people
appear to be experiencing symptoms akin to post-traumatic
stress disorder (PTSD), but these are not being
recognised.
People with mental illness and
drug use
Many people with mental illness use drugs. There are
significant service gaps between the different service
sectors for people with mental illness who are also
illicit drug users. There is a total lack of coordination
between the mental health services and drug and alcohol
services. In addition, there appears to be limited
expertise and little or no case management
support.
Women
Overall our consultation identified that the mental
health system continues to have difficulties dealing with
the issues of domestic violence, sexual assault and with
survivors of child sexual assault.
Women from a NESB with mental
illness do not have access to gender specific, culturally
appropriate information. In some communities women with a
mental illness can be quite isolated and if there are
significant levels of stigma or misconceptions (such as
mental illness being a genetic condition) attached to
having mental illness, women are likely to hide their
mental illness.
Housing Issues for people from a
NESB with mental illness
People from a NESB with mental illness are missing
out on public housing. They cannot get approval for
priority housing because they do not realise how much
information is needed from doctors, social workers, etc
to support their application.
If people do get housing they are
more likely to be harassed or victimised because of their
ethnic background and/or their mental illness. In
situations of conflict between tenants the Department of
Housing often finds it easier to 'get rid' of the person
with the disability than to deal with the issues of
racism and disability phobia.
The Department of Housing also
continues to allocate housing inappropriately to many
people with mental illness in large estates where housing
standards are mostly poor and tensions are high, adding
pressure on the person's already fragile mental health.
In addition, the current Memorandum of Understanding
between the Department of Health and the Department of
Housing does not have a significant positive impact on
people from a NESB, as they have low mental health
service utilisation rates.
MDAA is extremely concerned about
the recently announced social housing 'reforms'. For
example, from now on tenants are placed on 'time-limited,
renewable leases'. This means that the Department of
Housing can simply ditch 'difficult tenants' at the end
of the lease onto the private market, with the promise to
a private owner who is prepared to take on 'difficult to
place tenants' of $1,000 as compensation if the tenancy
'goes wrong'. With few support services and tenants
facing harassment and discrimination, and an owner who at
the very least is tempted by the prize of $1,000, it
seems almost inevitable that these tenancies will 'go
wrong'. The proposed bonds and the Home Aides schemes
also announced by the Housing Minister will also mean
additional stress and further vulnerabilities for public
housing tenants from a NESB with disability.
MDAA is extremely concerned that
the recently announced reforms to public housing will
only add pressure to an already overloaded Supported
Accommodation Assistance Program (SAAP), which has not
enough stock and resources to cope with current
demand.
7.7 Promoting and facilitating
appropriate and effective partnerships between mental
health services, consumers, carers and non-government
organisations.
Our consultation revealed that
there are not many links between NESB-specific services,
general community services and mental health services.
For people from a NESB the intersections between the
systems are fragmented and not easily breached
(traversed?).
As discussed above there are no
natural or systematic networks between NESB and mental
health services.
Involvement of consumers and carers
in the mental health services is totally under-developed.
The existing Consumer Advisory Groups are basically
Anglo-Australian institutions.
7.8 Supporting ongoing research
and evaluation on the mental health and service needs of
people from culturally and linguistically diverse
backgrounds.
In terms of research and
evaluation, the most significant document for mental
health service provision for people from NESB in NSW,
"Caring for Mental health in a Multicultural Society",
has not been evaluated and reviewed.
