5.5Role of ethnic communities in developing appropriate psychiatric services
Mentally ill patients have specific religious, cultural and language needs which must be met. The Mental Health Act 1986 requires the Health Department to "consult with appropriate ethnic groups and to employ and train ethnic persons in the provision of mental health services" 1
The Ethnic Communities Council of Victoria (ECCV) is an umbrella Organisation consisting of some 80 affiliated organisations representing about 30 different ethnic groups from metropolitan as well as rural areas. Through a number of committees, including a Health Committee, it is in a position to examine and make recommendations relating to a number of issues. The ECCs of all States are affiliated to constitute the Federation of Ethnic Communities Councils of Australia (FECCA), through which matters of national interest may be discussed and implemented.
In proposing a role for the ethnic communities and for the ECCV in particular, it is essential to examine the problems and issues as we see them.
The special problems met by members of the ethnic community have been summarised in a number of publications, including a recent paper by the Office of Psychiatric Services (OPS) 1, as well as in a workshop on mental health in Adelaide 2. These highlight several deficiencies:
- Psychiatric services are called upon only when illness is very severe because of ignorance, difficulties in communication, stigma attached to mental illness, or lack of appropriate services available.
- There is a lack of understanding and communication with the patient because there are few who have the language and cultural training necessary.
- There is a lack of clear guiding principles relating to planning, management, and relative responsibilities for clinical services.
- There is little understanding of the effects of particular experiences including the process of migration, or other specific experiences such as torture, refugee status and racism in the community.
- There are barriers hindering access to mental health services, including lack of information, bilingual workers, interpreters and health professionals, particularly in rural areas.
- There is a lack of networking between mainstream programmes and specifically targeted programs, and between those in public, private and voluntary health sectors.
I would like to stress some particular situations where mental health services to the ethnic community need special attention.
Geriatric services for three main categories of patients may be identified namely:
- Those with a long standing psychiatric disorder who have now grown older.
- Those with functional psychiatric illness which develops later on in life, e.g. depressive disorders or neuroses .
- Those with psychiatric or behavioural sequelae to an organic brain syndrome.
With an ageing population this is likely to become a subject of overriding importance. It is estimated that the proportion aged 65 years and above will rise by 30% in the next 10 years and that over the age of 80 years will rise by 60%.
With increasing age we find an increase in the incidence of psychiatric disorders. About 2% of persons aged 65-69 and up to 18% of those aged over 80 years will suffer from dementing disorders (Willsmere Project Working Party No.3 Report.3). These figures imply that the number of persons with dementia will increase by about 50% by the end of the century. Another 15% of older persons have other, less severe psychiatric disorders that require community-based psychiatric treatment.
This is likely to impose an enormous strain on available resources and invariably this means that more reliance is placed on services provided by carers who are most likely to be relatives of the patients.
Women experience high rates of stress, anxiety and depression and certain psychiatric illnesses. For ethnic women these are compounded through "the migration process, their experience as refugees,- settlement in a new country, inability to speak or understand English, the break up of their extended family unit, their loss of status, adoption of new and additional roles, their coming to terms with a new lifestyle, rearing their children within a new environment or combination of these factors"4. This in turn leads to increased use of psychotropic drugs such as tranquillisers, anti-depressants, and sedatives all of which have risks and side effects particularly when taken for a long period of time.
Variation in level of provision of psychiatric services
Another problem we face is the great variation in the availability of mental health services. The distribution of psychiatric hospitals, as well as, that of community mental health centres bears little correlation with pattern of need.
Let's take Community Mental Health Centres as an example. A community health service should provide "A comprehensive and relevant range of health services, with emphasis on illness prevention, health promotion and early intervention" 5. However, the availability of services varies enormously from State to State and within States from one region to another. Different local councils have tackled the problem with a varying degree of zeal.
Data relating to discharges from State Psychiatric (Acute) Hospitals (1986/87) also show considerable ethnic variation, with more than twice the number of discharges for Vietnamese (4.1/1000pop) compared to the Australian-born population (2.0/1000) (1). The ethnic communities most represented in hospital discharge statistics are shown in Table 5.1.Whether these figures reflect differing prevalence rates or merely referral patterns and variability in the amount of availability of community health care is hard to judge.
Table 5.1:Discharges from State Psychiatric (Acute) Hospitals, by Country of Birth
Country of Birth
Discharges per 100,000
It is clearly important to identify those areas with a high ethnic community concentration and examine the availability of services in such areas. It is also important to emphasise the needs of country areas where services are likely to be less concentrated than in the Metropolitan region, and where distances would make hospitalisation more of a problem.
Health Service Agreements
A recent trend is for the Health Department to negotiate a "Health service agreement with the individual health service agency. While theoretically this may have a number of advantages, particularly from the point of view of planning the service, models that are in existence fall short of the ideal. The ethnic involvement in such agreements is minimal and largely tokenistic. In one such recent "agreement", mention is made several times of needs and requirements for ethno-specific services, however, nowhere is it indicated how this is to be done. For example, there is no recommendation relating to improvement of interpreter service, no priority listing under the title "goals", and no ethno-specific services are included under the heading "Key Initiatives".
Mainstream versus specific services
A question often raised relates to the relative merits of mainstream versus ethnic-specific services. A balance between culturally sensitive mainstream services, ethno specific services and a mixture of the two are the available choices. While it is very difficult to imagine the establishment of ethno-specific psychiatric hospitals and other major institutions, it is essential to appreciate that too often the first call for help comes to the isolated social worker employed by a specific ethnic community, and this is to be strengthened and encouraged through adequate funding.
It is worth pointing out, moreover, that ethno-specific agencies and organisations have often taken the lead in identifying needs and in responding to them where there has been no response from mainstream agencies.
The dangers of ethno-specific services have been (over?) emphasised. It has been argued that "by attributing a migrant's mental health status to ethnicity, factors which may be more remedial or relevant, can be obscured. These factors include the inadequate command of English as a major correlate of poor mental health, but also lack of income or wealth, low social status or class, and the actual circumstances of migration and adjustment." 1
Social status, economic conditions, and command of English may indeed be significantly correlated with mental health, however this is no argument for dismantling ethnic-specific services - rather it is an argument for making such generalist services more readily accessible to the ethnic community. Ethno-specific services complement and do not replace mainstream services.
Ethnic community needs
The Victorian Government policy guidelines relating the health care for people of non-English speaking background are summarised in The Ethnic Affairs Principles: 6. These are:
- All services should be accessible to all residents of Victoria regardless of their language or birthplace.
- Services should be located as close as possible to the community using them.
- All residents should have opportunities to use and shape the services they need.
- All services should be responsive to differing cultural values and expectations.
- All services should have access to interpreters and translators to facilitate access and participation.
We would support such general principles and would emphasise the need for
1. Provision of bilingual staff for all aspects of continuing care, namely:
- specialist treatment and therapeutic services
- community support and rehabilitation
- services for isolated persons
The difficulties involved with use of interpreters in mental health assessment and diagnosis argue for direct bilingual staff requirements. This implies recognition of overseas qualifications, and a sensitive policy with regards to recruitment of qualified persons overseas. It also implies monitoring of available personnel being trained at the moment, largely involving second generation students of NESB parents.
2. Availability of qualified interpreters.
3. Improved consultation of service providers with:
- ethnic communities
- ethnic community councils and umbrella organisations
4. Involvement in policy making at various levels, including Regional Planning, Health services agreements, District health councils, special mental health units, e.g. the Victorian Transcultural Psychiatry Unit, the Mental Health Interpreter Service, etc.
5. Involvement in education of the ethnic communities relating to psychiatric matters. Provision of appropriate information (in various languages) through print and electronic media.
Role of the Ethnic Communities Council of Victoria
The ethnic community and the ECCV in particular should have a role in participating in some of the issue mentioned. The ECCV is in a special position through its involvement with the various communities as well as with the Governmental bodies, and therefore I believe it can have an input at various levels. These can be summarised as follows:
1. To provide a forum for discussion and debate among the various ethnic communities regarding mental health issues.
2. To advocate and lobby on behalf of the ethnic community as a whole, in the Metropolitan as well as regional areas of Victoria.
3. To liase and participate with Governmental instrumentalities in the formulation of policies relating to
- identification of priority areas
- reviewing mental health services, both specialist and generalist requirements
- initiating plans for further mental health services
- lobbying for funds.
4. In particular the ethnic communities should have an input at the point of service delivery, be it hospital, or community health service. Involvement at hospital Board level by NESB persons is one glaring example of lack of participation.
5. To help in the education relating to mental health. This includes:
- understanding mental abnormalities
- understanding problems of carers
- encouraging ethnic communities to take up professions like nursing which may not be highly appreciated by ethnic groups
- foster discussion relating to alternative forms of mental treatment.
Health education represent special problems for the ethnic community. In all areas of health epidemiology, but particularly in psychiatric conditions, one needs to develop a strong education campaign. The HDV proposes to develop such a wide ranging educational and promotional campaign to reach all, including the ethnic community. In the words of the Planning Guidelines, Health Department of Victoria 6, "There should be greater outside participation and consultation in the process of campaign planning. In particular there should be consultation with people who are familiar with the special needs and cultural patterns of different ethnic communities as part of priority determination and campaign planning."
6. Help with recruitment of staff through discussion and highlighting problems in the ethnic media.
In conclusion, various studies have emphasised the special and specific needs of the ethnic communities in relation to mental health. Various solutions have been proposed largely contingent on expenditure of an ever-increasing amount of funds which we are assured are hard to come by. It is, however, now understood that no service can adequately cater for the needs of a clientele unless there is a serious attempt at involving them in the process of service delivery. It is through such involvement the ethnic communities and particularly the ECCV as an umbrella Organisation can contribute to the process of equitable disruption of the available services and resources.
- Office of Psychiatric Services: Discussion Paper: Issues in the Provision of Psychiatric Services to People from non-English speaking backgrounds. HDV. 1987.
- Mental Health and Ethnic Communities, Workshop 7, Proceedings and Workshop recommendations for National Ethnic Health Policy Conference, Adelaide, April 12-15, 1988.
- Office of Psychiatric Services: Psychiatric Services for Older People in Victoria - Policy and Program Statement, HDV, May 1988.
- Health Information Paper, HDV, 1987.
- Ministerial Rev of Community Health, May 1985, p5.
- Health Care for People of Non-English speaking Background. HDV, Draft Planning Guidelines, 1988.
[Reproduced from: Minas IH (ed.) (1991) Cultural Diversity and Mental Health. RANZCP-VTPU. P 57-64]
Source: Maurice N.Cauchi - The Maltese Migrant Experience, Malta 1999