Submission to HRECO and
 the Mental Health Council of Australia

Services > Systemic Advocacy > 2004 Submission to HREOC - October 2004

1. Introduction

1.1 About MDAA

The Multicultural Disability Advocacy Association of NSW (MDAA) is the peak body in NSW for people from a non-English speaking background (NESB) with disability and their families and carers.

MDAA is the only advocacy service in NSW specifically available to people from a NESB with disability, their families and carers.

MDAA is working towards:

• Promoting, protecting and advocating for the rights of people from a NESB with disability and their families and carers in NSW
• Contributing to a process that ensures access & equity for people from a NESB with disability and their families and carers in NSW in the government and non-government sector.

1.2 Sources of evidence

For this submission we have used several sources of evidence:

• Our experiences with people from a NESB with mental illness through our work as advocates. MDAA has been advocating for people from a NESB with mental illness since 1995 and we have acquired significant experience and knowledge in this area. In 2003-2004 we have supported 142 consumers who have identified a psychiatric disability as either their primary or secondary disability. It is important to note that we also work with a significant number of people who have a mental illness and intellectual disability. Our work is with people from all cultural backgrounds except Anglo-Australian and therefore our expertise is not about one particular cultural group.
• Previous submissions (including our Submission to the NSW Upper House Inquiry into Mental Health Services 2002), previous research (including "Reality Check" undertaken by NEDA) and participation in consultations and discussions (including the Day of Action organised by the Mental Health Coordination Council of NSW).

We urge the Inquiry to collate other sources, as much work has been done in this area and in this submission we do not want to duplicate work previously undertaken.

2. Key Issue: Systemic Racism

While MDAA appreciates the focus of the community consultations on experiences and 'stories', our expertise in this area clearly identifies that if the system is to deliver positive outcomes to people from a NESB, the single most important hurdle to overcome is systemic racism. To put it bluntly, the system is designed to deliver outcomes for people from Anglo-Australian background. People from a NESB have effectively two options, firstly to assimilate into a service system that operates at systemic, community and organisational levels to meet the needs of Anglo- Australians (however badly) or secondly, to simply not receive a service at all. The last option disappears once people are forced to interact with the mental health system as scheduled patients, forensic patients, etc.

Overall the system lacks cultural competence and operates as though it is dealing with a culturally homogeneous group. e The development of Transcultural Mental Health Centres and networks has brought the benefits of expertise and the development of knowledge and skill in dealing with people from a NESB with mental illness and their families and communities regarding policy issues, organisational issues and community issues. The 'down side' of the development of those centres and networks is that this has also led, in effect, to a sidelining of transcultural mental health issues as an area of specific expertise, which functions either to exclude practitioners or 'let them off the hook'.

This attitude of transcultural mental health being an add-on, an extra bit extends to all levels of service delivery:

• On a personal, individual staff level, cultural competence is perceived as something that bi-lingual/ cultural workers have. Generally the response to people from a NESB is to refer them to a bilingual worker, whenever possible. For indirect workers, such as health promotion staff, cultural considerations are at best an afterthought and certainly not part of their core business.
  
  
• On an organisational level, issues of culture are on the whole discussed as either a problem (with either consumers or staff from a NESB) or as something to be dealt with as a 'special' project. Cultural competence of the staff and organisation remains something specialist services do.
  
  
• On a community level, education/ promotion/ information provision targeting ethnic communities remains the expertise of specialist, ethno-specific and multicultural services. For mainstream campaigns information is at best simply translated with no or little attention being given to cultural understanding and ways of communicating within different ethnic communities. This is also true for new inditiatives, eg, enhancing the role of GPs, with significant resources being spent by the Commonwealth but no real commitment to a positive impact on NESB communities.
  
  
• On a policy level, the responses to 25% of the population remain at best piecemeal and mostly contradictory. On the one hand there is lip service given to including NESB as part of the mainstream (this is mostly summed up in sentences such as 'The client's cultural, linguistic and religious needs are to be respected'). Those and similar references then become the justification for a reduction in ethno-specific workers within the 'mainstream'.
  
  On the other hand, specialist policies such as the NSW policy of "Caring for Mental Health in a Multicultural Society" or the yet to be developed policy/ framework by Multicultural Mental Health Australia, become the arena and responsibility of experts, most certainly not the responsibility of 'mainstream' policy makers, managers, etc.

In 2000 MDAA argued in relation to the disability services sector, that the current system is an Anglo-Australian system and that in order to move towards a service system that meets the needs of the culturally diverse population, all services delivered need to be in fact culturally diverse services. The argument would need to be made by existing so-called 'mainstream' services that there are sound reasons why they effectively run as ethno- specific, in this case Anglo-Australian, services.

3. A culturally competent Mental Health Service Model

The two components of such a model essentially include:

3.1. Culturally Diverse Services

This would be the standard model of operation with services providing for all people of the target group (for example people with mental illness) in the community, regardless of their cultural and linguistic background. Given the cultural diversity of the community, every service must become culturally diverse.

These services would work with all members of the community and purchase culturally specific expertise from ethno-specific services when needed. These services would make up the bulk of the service types.

3.2. Ethno-Specific Services

This would be the exceptional way of service provision. An ethno-specific service would need to justify why it needs to be ethno-specific. Thus, a current Anglo-Australian service would need to justify why it is run as an ethno-specific service.

There are reasons why a service might be allowed to operate as an ethno-specific service. For instance:

• to provide to a particular cultural or linguistic group only, where specific cultural or linguistic needs and requirements can be demonstrated; and
• where a particular service model is demonstrated to be more appropriate for delivering services to a particular cultural group only. (www.mdaa.org.au/faqs/cultural.diversity.html)

4. Human Rights perspective

From a human rights perspective, people not only have a right to non-discrimination (as expressed in various state and federal Anti Discrimination legislation), the International Covenant on Civil and Political Rights includes as a fundamental right the recognition that ethnic, religious and linguistic minorities have a right to a distinct culture. MDAA argues that this fundamental right is not available to people with mental illness as they, in order to receive services, need to relinquish that right.

In 'On the Sidelines' HREOC argues

"As a nation, Australia has a moral and legal obligation to recognise, promote and protect the human rights of people with disabilities from non-English speaking communities. International human rights instruments and Australian domestic law seek to provide people with disability from non-English speaking background communities:

• fundamental civil, political, economic, social and cultural rights;
• non-discriminatory treatment by the society as a whole;
• the opportunity to develop and maintain their own culture and language; and
• freedom from racism and other forms of discrimination.

Yet people with disabilities from non-English speaking backgrounds seem potentially at risk of breaches of their right to non-discrimination. The history of Australian migration confirms that language and cultural differences can be significant barriers to the full enjoyment of human rights. The recognition of the right to non-discrimination places an obligation on Australian social structures to ensure that people with disabilities from non-English speaking backgrounds enjoy substantive equality irrespective of these differences.

The ICCPR maintains that immigrants, as new arrivals in Australia, have a right to join Australian society and enjoy the freedom and protection accorded to other citizens. Similarly, the ICESCR recognises that all Australians, including people with disabilities from non-English speaking background communities, have a right to a basic standard of living in order to fully participate in the Australian community. The human rights contained within these international conventions and the Australian domestic legislation implementing them, are important for people with disabilities from non-English speaking background communities. (From HREOC, On the Sidelines, 2000)

5. Specific issues

Below, in no particular order, is a list of issues raised repeatedly by consumers, families and MDAA staff in forums and other events. They are collated from a range of documents, such as submissions, notes from consultations, etc.

5.1 Access to information

Information on mental health and mental health services to people from a NESB is limited. The information available is usually very basic. The few materials available are generally pitched at community education level. Very little is available in 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 simply to have been translated with no regard to getting the information across in a culturally sensitive manner. For example, while the term '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 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 actively seek 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 with the dissemination 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 about 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 their specific 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 among many NESB 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. (from MDAA Submission to NSW Upper House Inquiry, 2002)

Likewise stigma has not been addressed at all within communities and this continues to be one of the key isolating factors that people with mental illness and their families talk about.

From a rights perspective, there is almost no information for NESB communities about rights within the Mental Health System and about mental health laws.

5.2 Access to appropriate care (culturally competent services)

One of the key barriers to equity in mental health services is the overall low levels of cultural competence among 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 ascribes 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.

Furthermore, the current model of mental health care continues largely to disregard other models of care and non-Western approaches to mental health. Many of these 'alternative' approaches have 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 among 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). 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. (from MDAA Submission to NSW Upper House Inquiry 2002).

The following is a list of other issues raised on various occasions in the context of service provision:

• current services stretched in terms of resources, therefore NESB issues just appear to be another burden, nothing to do with good practice;
  
  
• there is insufficient and inadequate training for staff to deal with people from a NESB;
  
  
• partnerships between mental health services, consumers, their families and carers at all levels of service delivery and implementation largely do not exist;
  
  
• people from a NESB are often referred to inappropriate services or there is a delay in addressing their needs (of migrants, refugees and other people from a NESB, aided by interpreters and culturally trained staff);
  
  
• there are culturally inappropriate assessments, diagnosis and treatment for people from a NESB; overall the lack of cultural competence of health professionals leads to wrong diagnosis or treatment;
  
  
• links between services are very limited or non-existent; services specifically available to people from a NESB have long waiting lists and cannot meet demands;
  
  
• absence of adequate work training of staff with NESB consumers and insufficient knowledge about related issues (such as torture and trauma, settlement difficulties, cultural differences that may have an impact on mental health);
  
  
• focus on early intervention is completely missing within NESB communities.

5.3. Parents with mental illness and child care and protection matters

Parents with mental illness (PTSD, psychosis) have their children removed from their care, because of their mental illness. It is clear form our involvement with consumers that some families could have stayed together if workers in the child protection system firstly had any understanding about mental illness and disability in general and secondly, an understanding of how cultural practices affect child rearing practices. Children are taken away from their parents and then placed in foster care where they often remain for long periods of time.

Additional problems arise where children, due to long periods of time in foster care, do not want to go back home and then become wards of the state or move continuously into different foster care arrangements. It appears that it is very hard for parents to get the children back, because they don't know the system and they are frequently told that legal aid is not available to them.

In NSW, the Child Protection System lacks understanding of mental illness and disability issues, as well as cultural competence, and instead of providing early intervention support and family support services; it appears that the more common response is a draconian one.

Case study¹ : Child protection

Biljana is a 36 year old woman with schizophrenia and a mild intellectual disability. She lives with her parents and her brother who also has schizophrenia. Biljana is a single parent and has a 2 year old daughter named Jelena. Prior to Department of Community Services (DoCS) intervening in 2003, Biljana and her extended family were caring for Jelena without any support and without any incident. While Biljana has an intellectual disability and was experiencing additional difficulties in caring for her child, like other families with additional difficulties (i.e. financial, family breakdowns, etc), there was no evidence of child neglect or abuse.

It just had happened once that Biljana's daughter Jelena injured her leg while playing around the house. As any mother would have done in similar circumstances, Biljana took Jelena straight to the Hospital for an assessment.

What happened next is unclear, but when the specialist attempted to find out how Jelena's injury occurred, her mother Biljana was unable to answer because of her limited English proficiency (the interpreter was not present at the scene) and her disability. To the untrained person she may have appeared as a parent unfit to care for her child. The specialist decided to inform DoCS about the incident.

In the advocate's first meeting with Biljana and her mother, Milanka, they expressed their confusion as to the reasons why DoCS took Jelena from their home. They could not understand the decision of DoCS who had seen it appropriate to institute care and protection proceedings. Nor did they understand the extended legal process involved in dealing with this matter. The family saw it appropriate to raise Jelena according to Croatian cultural values, and they could not understand why they were obliged to conform to other people's expectations about how they should raise their daughter and granddaughter, respectively.

Biljana and her mother both expressed great concern for the welfare of Jelena and great distress at not being able to have her back at home. Both Biljana and Milanka stated that they were willing to do anything possible to get Jelena back home, but did not know what DoCS expected of them. This is quite understandable, given that no such service exists in Croatia.

Unfortunately, the over-zealous DoCS workers appear to have little or no understanding of the Croatian culture (e.g. family and social relationships) or for that matter people with disability. They made an error in judgment by deciding to remove Jelena from the care of the family. It is important to remember that culture plays an important role in the family's perception of their parenting skills and re-education regarding the importance of Jelena's development has to be performed with respect to the family's cultural values. It is also imperative to understand that the way parents interact with their children in Croatia is quite different from how parents and children interact with each other in Australia.

5.4 Tenants with mental illness

Public housing remains the key concerns for many of MDAA consumers, many of whom have mental illness. There simply is not enough money in public housing and the Commonwealth through the last Commonwealth/ State and Territory Housing Agreement has basically abandoned Public Housing. In NSW, particularly in Sydney but also in many regions, there simply is not enough supply to deal with the demand.

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 introduced 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' onto the private market at the end of their lease, 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. Recent amendments to the residential tenancy laws will allow the NSW Department of Housing to require a tenant to sign an 'acceptable behaviour agreement'. If the tenant or anyone living with them breaches the agreement this will be sufficient reason for the Department to evict them. These amendments apply only to public housing tenants and in our view have the effect of further stigmatising people who live in public housing. We fear that the implementation of 'acceptable behaviour agreements' will result in homelessness for many tenants with mental health problems.

MDAA is extremely concerned that these '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.

Case Study² : Housing

Ramona is separated but living in the same house as her husband, her 3 daughters and her parents. She applied for priority housing in 2001 because she needed to find safe, secure accommodation to escape her husband's continuing violence. She has severe depression and finds it very difficult to care for her daughters in her current housing.

The Department rejected Ramona's application but approved her for 'wait turn' housing and offered her Rentstart³ to obtain private rental housing while she waited.

Ramona's depression prevents her from approaching real estate agents to find private rental housing. She also knows she would be ostracised and harassed by her relatives and friends in her community if she moved out to private rental housing with her children. When she filled in the priority housing application form Ramona did not know she needed to explain these cultural issues (self-evident to her) or set out the effects on her daughters of the violence they were witnessing, as well as the effects it was having on her. Her disability is such that she was unable to gather all the medical information she needed from her doctors or statements in support of her application by agencies who were aware of her circumstances. She was therefore unable to persuade the Department that she could not meet her housing needs through private rental housing or that her needs were more urgent than other women with violent husbands.

Ramona is considering an appeal to the Housing Appeals Committee.

 Raquel

Raquel lives in a public housing estate with her two children and is separated from her husband. She has mental health problems including severe anxiety and depression. Raquel's husband lives with another woman from the same ethnic community and visits Raquel's home often to help care for the children. He stays over-night sometimes; especially if Raquel's mental health requires this.

The Department received information from a person who did not identify himself, alleging that Raquel was defrauding the Department regarding her rental subsidy by falsely claiming to be separated.

The Department investigated the allegations by visiting Raquel, who complained that the officers concerned were rude to her, threatened her and asked unnecessarily intrusive questions. They showed no sensitivity to the nature of her disabilities and no awareness of the cultural considerations which led Raquel and her husband to behave in ways that hid their separation from other members of their community (both parties would have been ostracised, particularly Raquel, who would also have been at risk of physical violence from members of her family).

Raquel had notified the Department before the investigation that one of her children had been involved in an accident and that she needed extra help from her husband as a result. The investigating officers told her there was no evidence of her notification on the Department's files. Raquel was extremely distressed and highly anxious that the Department believed she was trying to defraud them. Her mental health deteriorated as a consequence of the investigation.

 Nadia

Nadia has mental health problems which are exacerbated by occasional drug or alcohol abuse. She lived in a public housing unit but wanted to move back to her parents because she felt isolated and lonely. Nadia's relationship with her parents is fragile: sometimes they are very supportive, but at other times they cannot cope with the care her disability requires at the time.

The Department told Nadia it would remove her name from the housing register when she moved back to her parents. With advocacy assistance Nadia persuaded the Department to leave her name on the register for a few months in case her relationship with her parents broke down after she went back to live with them. Past experience indicated that this was likely to occur. 

George

George has mental health problems and came home one day to find that the Department had entered his flat without permission after receiving allegations that no-one lived there. His neighbours had been making racist remarks and generally making his life miserable for some time. They told him several times that they wanted him to leave. George is the only single member of his family and spends most days with his father who needs care and support because he is very ill. George comes home most nights to sleep at his flat.

The investigating officer threatened to evict George and told him that he did not have enough furniture in his flat to prove he lived there. The officer told George he would have to tell the Department whenever he went away. George thought it was none of the Department's business how much furniture he had or if he went away for a week or two. He always came back because his flat was his home. George asked the Department to stop the neighbours from bothering him.

The investigating officer told him there was nothing the Department could do about that.

5.5 Access to interpreters

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. (MDAA Submission to Upper House Inquiry 2000).

5.6 Social Security

Overall, the social security system has demonstrated that it is exceptionally inept in dealing with disabilities that are not obvious and disabilities that may be episodic in nature. It appears that the whole system is set up to work best for people with physical disability. Everyone else has to hope to be referred to a good Centrelink Disability Officer.

Case study: Social Security

Mrs Milica Veselinovska last worked in 2003. She lodged a claim for a disability support pension (DSP) in February 2004 and was examined by a Rehabilitation Consultant 2 months later who assessed that Mrs Veselinovska has chronic lower back pain, osteoarthritis and degenerative changes in her lumbar spine. He also found that Mrs Veselinovska may be able to return to a different type of work within six to twelve months following English training and vocational rehabilitation. Her claim for DSP was however rejected on the grounds that Mrs Veselinovska overall has a total impairment rating of only 10 points (half what is needed to qualify for the DSP).

The advocate checked all relevant medical records provided by specialists and discovered that Mrs Veselinovska had been diagnosed with a serious mental illness. This medical condition was not taken into account by Centrelink and therefore Mrs Veselinovska's claim for DSP was rejected. The advocate assisted Mrs Veselinovska in filling out a form to send to the Authorised Review Officer at Centrelink and wrote a letter of support explaining her condition. The Authorised Review Officer reviewed the documentation and decided that Mrs Veselinovska should receive the DSP.

5.7 Involuntary patients and high representation at the crisis end of mental health services

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. (from MDAA Submission to NSW Upper House Inquiry 2002)

Case study: Involuntary Patient

Federica is a 40 year old woman who arrived in Australia as a refugee. Federica has a mild to severe intellectual disability and a Post-Traumatic Stress Disorder. She recently experienced an episode in which, according to her case manager, Federica's behaviour was so irrational as to 'justify a conclusion on reasonable grounds that temporary care, treatment or control was necessary for her own protection or the protection of others from serious physical harm'. Following this episode, Federica was admitted to the psychiatric unit of a hospital where the proposed treatment program included the administration of antipsychotic drugs. In a lucid interval, Federica indicated her refusal of such treatment. However, she was persuaded by her case manager (who ignored the fact that Federica was incapable of understanding and weighing information due to her disability), to consent to the medical treatment proposed.

When Federica was discharged from the psychiatric hospital she was placed under a Community Treatment Order which set out a decision made by a Mental Health Review Tribunal. Although an interpreter was present at the hearing, the family could not understand what was going on during the proceedings due to limited English proficiency and unfamiliarity with the legal system in Australia. It later became obvious that the interpreter spoke a different dialect from the one Federica understood). On several occasions the family tried to revoke the Community Treatment Order but had no success.

When Federica's sister Susan came to MDAA she was very confused and distressed. She explained what had happened to her sister and provided some supporting medical evidence. It was when reading this evidence that the MDAA Advocate noticed that Federica was most likely misdiagnosed by the health care team. The advocate found evidence suggesting that Federica's episode of erratic behaviour was due to her mother having suffered a stroke and being taken to hospital in a critical condition. This evidence was not taken into account when Federica's mental state was assessed.

5.8 Dual Diagnosis: People from a NESB with a mental illness and an intellectual disability

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. While there are few practitioners skilled in relation to dual diagnosis generally, there are virtually no skilled practitioners working with people from a NESB with dual diagnosis. (from MDAA Submission to NSW Upper House Inquiry 2002).

Case study: Dual Diagnosis

Fatima is a 42 year old woman with dual diagnosis. She has an intellectual disability and was recently diagnosed with acute schizophrenia by a psychiatrist. Fatima does not speak English and has no capacity to understand long and abstract verbal instructions, even in her native language. When Fatima's sister contacted MDAA she told the advocate that Fatima lacks basic living skills and lives a very isolated life

Despite the recent diagnosis by the psychiatrist, there was conflicting evidence about her mental health status and a referral was made for a transcultural Mental Health assessment. After the assessment Fatima was referred to a local Mental Health team for counselling. Fatima was rejected there because she has an intellectual disability and therefore she was perceived to be unable to follow instructions.

On the matter of providing some basic living skills training for Fatima, the advocate tried to make a referral to a Living skills program but was refused because they were unable to work with someone who has dual diagnosis and does not speak the language.

6. Conclusion

MDAA acknowledges that there are many shortfalls and difficulties for many people who come into contact with the mental health system and overall the community services system and other government and non- government sectors and agencies do not cope with the mental health needs of the general community. However, in our experience the situation is much worse for the 25% of people in the community who are from a NESB.

To redress the current race inequalities requires leadership. MDAA urges HEROC as the body working towards an Australian society where the human rights of all are respected, protected and promoted and MHCA as the independent, national representative network of organisations and individuals committed to achieving quality mental health for everyone in Australia to take on this leadership and work towards achieving human right and quality mental health services for people form a NESB with mental illness

1. Each case study describes the experiences of a particular MDAA client. The clients' names have been changed and some identifying details withheld to protect their confidentiality.
2. the following housing case studies are from MDAA report " Hitting the Roof" 2003
3. 'Rentstart' may provide financial assistance for bond, rent in advance, service connection fees and removal expenses, depending on the applicant's circumstances.