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EVALUATING MENTAL HEALTH SERVICES FOR NON-ENGLISH SPEAKING BACKGROUND COMMUNITIES

Helen Long, Jane Pirkis, Cathy Mihalopoulos, Lucio Naccarella, Michael Summers, David Dunt

Evaluating Mental Health Service Frameworks for non-English Speaking Background Communities by Dr Helen Long, Jane Pirkis, Cathy Mihalopoulos, Lucio Naccarella, Michael Summers, and A/Prof David Dunt. Centre for Health Program Evaluation

Published by: Australian Transcultural Mental Health Network Melbourne, 1999.

ISBN: 0 9585975 5 3

1999

This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of an acknowledgement of the source and commercial usage or sale. Reproduction for purposes other than those indicated above requires the permission of Multicultural Mental Health Australia. Addtional copies of this report are available from Multicultural Mental Health Australia Locked Bag 7118 Parramatta BC 2150 admin@mmha.org.au Tel: 61 2 9840 3333 Fax: 61 2 9840 3388 Artwork, Design and Preparation by Peter Wellington

Table of Contents page number

EXECUTIVE SUMMARY

CHAPTER 1 INTRODUCTION

1. 1. 1.2. 1.3. 1.4. 1.5. 1.6. 1.7. 1.8.

1 1 2 3 4 5 6 8

Purpose of the Report The Utility of the Report The Scope of the Study Data Collection Methods Issue Identification and Analysis Development of an Evaluation Framework Testing the Framework: 3 Case Studies Structure of the Report

CHAPTER 2 THE ACCESS OF PEOPLE OF NESB TO MENTAL HEALTH SERVICES

2.1. 2.2. 2.3.

9 13 15

Entitlement of People of NESB to Mental Health Services The Nature of the Need Barriers to Service Access

CHAPTER 3 IDENTIFYING EFFECTIVE APPROACHES TO INCREASING ACCESS

3.1. 3.2.

26 33

Models of Best Practice Overcoming the Barriers in Practice

CHAPTER 4 DEVELOPING THE EVALUATION FRAMEWORK 4.1. 4.2. 4.3. 4.4.

Scaffolding for the Evaluation Framework: National Standards for Mental Health Services The Evaluation Framework for Best Practice The Criteria The Worksheets

41 41 43 44 47

CHAPTER 5 THREE CASE STUDIES OF CURRENT PRACTICE

5.1 5.2.

5.3. 5.4.

Introduction Case Study 1: Mid West Area Mental Health Services (Melbourne, Victoria) Case Study 2 Rockingham Kwinana Psychiatric Service (Perth, Western Australia) Case Study 3: Princess Alexandra Hospital and District Mental Health Service (Brisbane Queensland)

61 79 88

CHAPTER 6 CONCLUSION

100

APPENDICES REFERENCES

102 144

List of Tables TABLE 1:

TABLE 2:

OCCASIONS OF INTERPRETER USE (VICTORIAN INTERPRETING AND TRANSLATING SERVICES) BY MID WEST AREA MENTAL HEALTH SERVICE, 1 APRIL TO 30 SEPTEMBER 1997 BILINGUAL STAFF EMPLOYED BY MID WEST AMHS, BY LANGUAGE GROUP TABLE 3: MATRIX STRUCTURE OF PRINCESS ALEXANDRA HOSPITAL AND DISTRICT MENTAL HEALTH SERVICE

Appendices page number 1. Criteria for Best Practice in provision of Access to Public Mental Health Services for People of NESB Throughout Australia 104 2. Project Contacts 109 3. Identification and Evaluation of Innovative Models of Mental Health Service Delivery for NESB Communities: Project Summary 112 4. Centre for Health Program Evaluation. Letter Re: Case Studies 113 5. Western Healthcare Network Ethnic Mental Health Consultant: Position Description 116 6. Western Health Care Network - Mid West Area Mental Health Service. Position Description for Bilingual Case Manager 119 7. Western Health Care Network Mental Health Program (Draft). Policy and Procedure for culturally Sensitive Practice 122 8. Western Health Care Network Mental Health Program: Mid West AMHS Strategic Plan 132 9. Western Health Care Network Mental Health Program: Mid West In-Patient Unit Strategic Plan 136 10.Western Health Care Network Mental Health Program: Mid West MST Plan 137 11.Western Health Care Network Mental Health Program: Mid West CATT Strategic Plan 138 12.Western Health Care Network Mental Health Program: 141 St Albans CCU Strategic Plan Addendum to Appendix 144

Acknowledgements The authors would like to thank the many individuals and services throughout Australia who assisted so generously in cooperating with the project. The support staff at the Centre for Health Program Evaluation provided willing and helpful assistance throughout the project. The Australian Transcultural Mental Health Network (ATMHN) is funded by the Commonwealth Department of Health and Aged Care as a part of the National Mental Health Strategy.

iii

EXECUTIVE SUMMARY This report documents a project funded under the National Mental Health Strategy. The project was commissioned by the Australian Transcultural Mental Health Network, and undertaken in the Centre for Health Program Evaluation at the University of Melbourne. It aimed to consider the main barriers which people of non-English speaking background experience when they need public mental health services. The project explored both these barriers, and service responses to them in the Australian context, and in the academic literature. Consultation was carried out with clients, service providers and people familiar with the problem of access. It sought to identify ways in which these barriers might be overcome, and to gather opinion as to which of these ways are acceptable and effective. The project then considered how services might easily and effectively track and respond their own performances in providing good access to people of non-English speaking background within their catchment areas. Models for assessing and improving access were examined, and considered in the light of the issues raised in consultation and in the literature. The context of government policy was also examined for the principles governing and informing standards or ideals of such access. On the basis of this research, and in the light of the National Mental Health Standards which now provide the “gold standard” or benchmark for quality in the provision of public mental health services in Australia, a framework for self-assessment or evaluation by mental health service providers was developed. This framework is modelled on the national Standards, and consists of two component parts. These are: • A set of criteria against which a service may assess its performance at any time and over time • A set of worksheets where a service may document current projects related to fulfilling a criterion, as well as personnel responsible for this aspect of service and time lines for the next achievement. This framework was then checked in three Case Studies for its relevance and appropriateness. It was not actually used within these services. However, it was used after the Case Studies were completed to assess individual performance in promoting access, and was found to be relevant and useful in both well-developed and new services. Both issues of access and service responses to these issues have been explored in terms of five themes which recurred in the data gathered in the project. These are: • Language • Information • Communication • Stigma • Cultural differences between client and clinician.

The project thus followed through from identification of important issues to responses made by services, government and communities, to incorporating these in an evaluation framework, to actual evaluation. The outcome is a relatively simple, authoritative, widely applicable and useful evaluation tool which can be used throughout Australia to assist mental health service managers improve the access to their services which non-English speaking background people should have.

CHAPTER 1 INTRODUCTION 1. 1. Purpose of the Report The Australian National Mental Health Policy (Australian Health Ministers 1992) has acknowledged that people from non-English speaking backgrounds (NESB) have special needs which should be recognised in the planning and delivery of public mental health services. Evidence suggests that the rates of mental illness in NESB communities are generally higher than in the Australian-born community. There is also evidence that NESB people are admitted to hospital at lower rates than the Australian-born population, and that there is a lower rate of both voluntary and involuntary admissions for NESB people. There is a lower rate of use of community mental health services by NESB people, with a tendency for them to attend bilingual private psychiatrists and GPs (Ziguras 1993, Fitch et al 1992, Minas 1996). The National Standards for Mental Health Services specifically recognise these issues in outlining detailed criteria for best practice by mental health services across Australia (Australian Council on Health Care Standards 1997). In the context of these issues, the current project was commissioned by the Australian Transcultural Mental Health Network (ATMHN) with funding provided by the National Mental Health Strategy (NMHS) (Australian Transcultural Mental Health Network 1996). This Network is a program set up by the NHMS to promote a coherent, culturally appropriate national approach to mental health service development for NESB communities. This is being done through: 1 provision of support for the establishment and development of services; 2 collection and dissemination of information; 3 the development of national strategies for service development, education and research; and, 4 the funding of a limited number of special projects. This project is one of these special projects. The purpose of the report is to improve the access of people of NESB to public mental health services by developing and presenting a service evaluation framework which addresses the issues of access.

1.2. The Utility of the Report The report is designed to present to mental health service managers a description of the issues arising in the context of making their services optimally accessible to people of NESB. The evaluation framework developed to assist such managers to address

these issues should enable them to identify what practices will be important for improving this access. It should also help them to judge or measure their own success in implementing such practices within their service. These “best practices” in mental health service delivery should, in turn, address the specific issues which arise for people of NESB, which now serve to deny them effective access to services to which they are entitled.

1.3. The Scope of the Study The project is highly directed and specifically focussed on the development of a tool for use by community-based mental health services to help them to provide effective access. It acknowledges and seeks to accommodate the enormous diversity of mental health systems and services in Australia. It builds on the work of many in issue identification and in service model options, though existing documentation of these has been substantially complemented through interviews and case studies. It takes a pragmatic view of what kind of evaluation framework may be successful in the current climate of policy and practice, while addressing the identified issues. The scope of the project has necessarily been Australia-wide, and has drawn on reviews of experience in other countries, notably in the USA, itself a country with a long experience of migration, and where substantial changes in the structure of public mental health services have occurred in recent years. It has also drawn on information about structures, policies and practices across Australia. The emphasis has been on a breadth of approach, rather than in-depth studies in specific areas. The study has investigated the literature germane to the matter of NESB people’s access to mental health services, interpreting ‘access’ to include culturally appropriate, welcoming, wide-ranging and welladvertised services, as well as physically accessible ones. People of NESB who experience mental illness, who care for family members have been consulted, as well as NESB service providers and policy developers, have been interviewed, in order to obtain a sense of current issues in different parts of Australia. Existing Commonwealth, State and Territory policies have been examined and analysed, and models of good practice in this area have been examined and compared. Developments within the context of the National Mental Health Strategy have been seen as particularly relevant. Three Case Studies have been carried out to test the strength and applicability of the developed evaluation framework in three very different services. The breadth of the study has necessitated and valued a variety of approaches, rather than exhaustive investigations in any one aspect. The material accumulated has then been examined in order to identify contradictory and mutually reinforcing evidence, and to build a solid base for the evaluation framework. The project has been conducted by the Centre for Health Program Evaluation (CHPE), a research and teaching organisation within the Department of General Practice and Public Health at the University of Melbourne, and the Faculty of Business and Economics at Monash University.

1.4. Data Collection Methods Through the approaches set out below, the project sought to identify issues germane to the problem of inadequate access to public mental health services for people of NESB. It aimed to develop tools which would address these issues, and assist services to build more effective and innovative models of practice. Regular formal reports on the progress of the project were made to the ATMHN, and, more informally, contact was maintained with the ATMHN Co-ordinator. Two Reference Groups were set up to assist and advise the project (Appendix 2). One of these comprised people located in Victoria who represented a range of interested organisations, and another was made up of people from other States who were well placed to comment in an informed and constructive way on the project as it progressed. These Reference Groups were given copies of all ATMHN reports as they were developed, and feedback was requested. The role of these Groups was advisory. A Steering Committee within the CHPE also provided comment and advice on interim reports submitted at regular and frequent intervals over the project (Appendix 2). Consent from the University of Melbourne Ethics Committee to the conduct of the project within the proposed methodology was sought and obtained. Data for the project was collected in three principal ways. 1.4.1. Literature Identification and Review. Searches for relevant literature were conducted, and the recovered literature was read, classified, analysed and used in the report. This literature covers a wide range of subjects and formats, including academic articles, books, book chapters, monographs, conference proceedings and reports. The basic focus was on the problems experienced by people of NESB in gaining satisfactory access to public mental health services, and on the identification of models of service delivery which claim to address these issues. However, the search also identified statements of government policy as well as models of innovative practice and of program evaluation, together with analyses of their usefulness. 1.4.2. Consultation As well as the ongoing consultation made possible by the mechanisms set out above, the project also sought information and opinion from: • NESB mental health service consumers • NESB and non-NESB mental health service providers • representatives of community ethnic organisations • representatives of government departments and services • NESB GPs • representatives of torture and trauma associations (Appendix 2). In particular, continuing consultation occurred with consultants involved in the ATMHN project which focused on the role of primary health care providers to people of NESB with mental health needs.

This consultation took the form of providing written information about the project and its purpose, inviting written and verbal response. Visits were made to organisations in Victoria, Western Australia, New South Wales, Tasmania, Queensland and South Australia in order to see at first hand how services are actually provided to people of NESB. These services included ones involved in direct care provision as well as those of service development and advice, both general and specialist. Interviews were conducted with people in the above groups. Most of these interviews were formal, organised in advance with a summary of the project’s context and objectives provided. Subjects were assured of confidentiality, and notes were taken at the interview, with the subject’s permission. Other interviews were more opportunistic. Advantage was taken of a timely telephone call, or where an opportunity arose on interstate visits. In some instances, interviews proved impossible to arrange, despite repeated efforts at contact via mail and telephone, but information was obtained by other means. 1.4.3. Case Studies Three Case Studies were carried out, and the methodology employed for their conduct is set out below. As well as a way of testing the draft tools, and identifying innovative practices, the Case Studies also proved to be a valuable source of supplementary information, providing additional data for the refinement of issue identification and analysis. The observation of mental health workers carrying out their daily work made clear that “best practice” in the delivery of mental health services to people of NESB may to some extent reflect formal models or maxims. However, there is much in that daily work, and in the way it comes together to create a service, which is unrecorded, un-remarked, un-rewarded, but excellent and effective in assisting access - and needs to be “captured” so that it can be replicated. The Case Studies attempted to capture something of what occurs when best practice methods are implemented. These include: • management support, • in-service training, • appropriate financial resourcing, • the use of bilingual and bicultural workers, • the proper and consistent use of trained interpreters, and • demographic and cultural knowledge.

1.5

Issue Identification and Analysis

All of the above sources of data have been used in order to identify what it is in the situation of the person who is a migrant to Australia and unfamiliar with English, which creates special needs in them for “user-friendly” mental health services. The participants have established the taxonomy of this debate. These participants are those who have had the experience of both migration and mental illness, as consumers, carers or service providers. Those who have formally researched this experience, and analysed it in order to understand it, refer to aspects of this experienced need to identify reasons why the migrant unsure of English does not gain access to services. The approach in this

instance has been to survey a whole range of available data, and to identify and categorise issues as they are noted there, rather than to test an a priori hypothesis. This same process has been used to analyse the issues. Recurring themes in the literature, government documents, and in interviews have been identified, and the range of opinion described. These themes are: • Language • Information • Communication • Stigma • Cultural differences between client and clinician. It is through these themes that problems of access are explored, solutions reviewed, and a tool for self-evaluation by services developed and tested in this report. Consideration has been given to the position and perspective of the individual, organisation or author expressing a view, and commonalities noted. There has been a concern to document a wide range of views, and to draw a distinction between what ought to occur, and what actually occurs in practice. The former is set out in policies, models and guidelines. The latter was observed in the Case Studies and described by those interviewed, or by authors drawing on empirical research. From this basis of fact, opinion, observation and shared experience, the project has described the responses by governments and by mental health services which have been made to this need for better access. Reasons have been suggested as to why, in spite of (variable) recognition by governments, commentators and services of the need, and the proposal of detailed “innovative service models” to meet it, nonetheless it persists.

1.6

Development of an Evaluation Framework

With the identification and analysis of issues related to poor access of people of NESB to mental health services achieved, a framework for service evaluation was developed, according to the following criteria: • it should address the identified issues • it should be clear and unambiguous • it should be simple for management personnel in mental health services to use • it should take account of the huge diversity in mental health service structures in Australia • it should take account of the differences in policy at state level • it should build on work undertaken by the National Mental Health Strategy • it should help services to improve their performance in providing access to public mental health services for people of NESB, by indicating concrete areas where improvement might be sought, and the nature and extent of improvements, when they occur.

Accordingly, a draft evaluation framework was developed in close collaboration with the internal CHPE Steering Committee. It was preceded by an examination and analysis of various models which have been developed for services concerned to maximise access for NESB people. This framework included a range of criteria for service access effectiveness, and a way of recording service performance related to the criteria at any given time. These documents were circulated to and discussed with members of the local Reference Group. They were also sent to the wider Reference Group, to management in the Community Mental Health Centres involved in the Case Studies, and to individual members of the Australian Transcultural Mental Health Network for comment.

1.7. Testing the Framework: 3 Case Studies 1.7.1. Purpose When the draft criteria for provision of good service access were refined through this process of consultation, Case Studies in three Community Mental Health Services were conducted, in order to: • identify aspects of good practice in ensuring effective access to services • identify the important contextual and structural supports to this good practice in each case • identify the different opportunities for innovative practice which arise for different personnel within the Service • identify cooperative practices with other services and organisations which assist NESB access to the Service • trial the draft criteria with each Service, and to receive the response of the Service to the appropriateness and ease of application of the draft criteria. The Case Studies were set up as follows.

1.7.2. Location Three Community Mental Health Services, one each in Victoria, Western Australia and Queensland, were identified and targetted on the basis of advice from senior mental health professionals with expertise in NESB issues from these States (Appendix 13). 1.7.3. Negotiating Agreement The Director of each Service was telephoned and invited to participate in the proposed Case Study. They were informed about its content and purpose, and its place in the project as a whole. It was explained that the Project Officer wished to collect any available written information about the Service as a whole, and about its policies, particularly those facilitating services to people of NESB, about the population from which the Service drew its clientele, about actual NESB usage of the Service. All documents relevant to the purpose were sought. These included :

• • • • • •

position descriptions; details about the Service’s participation on inter-Service committees and projects related to NESB issues; any lists of bilingual service providers in the area drawn up to assist staff; details of training courses in NESB issues; anything provided by management to staff to assist them in responding to the needs of NESB people.

The Director was also informed of the approach to understanding the Service which the Project Officer wished to pursue whilst there. This included: • attending the Service over four days (two days in the case of Queensland); • interviewing the Director in order to understand management policy related to NESB people, and to explain the context of the criteria and the evaluation framework; • interviewing the Unit Managers to understand how they managed with relation to people of NESB, and their views on models of service provision to enhance access for these people; • interviewing at least one bilingual case worker in order to understand their role, and the issues they face in providing services; • visiting community-based and inpatient sites covered by the Service in order to understand the full range of the Service’s work, and the different contexts of this work; • attending case meetings, preferably in each Unit; • accompanying workers on home visits to people of NESB, with the patient’s consent, preferably where interpreters are used, and discussing issues arising from the visit; • attending assessments where NESB people are being assessed for their service needs with the assistance of an interpreter. It was emphasised that there should be no disruption to the work of the Service by the operation of the Case Study, and no variation in everyday practice, and that informed consent would be sought from clients and/or carers, as necessary.

1.7.4. Setting up the Study When provisional verbal agreement to each Case Study was given, a letter was sent to the Service Director. This letter: • set out the desired course of action in the Case Study; • attached a description of the project; • included a copy of a literature review; • included a copy of the criteria and the evaluation framework; • gave an undertaking that privacy would be ensured regarding all confidential information obtained in the course of the Case Study (Appendix 4). The Director was requested to distribute copies of this material to all Unit Managers, and to obtain any permission needed, eg from a Board of Management, for the Case Study to proceed. When this confirmation was provided by the Director, arrangements were finalised for the Project Officer to attend the Service for two or four days, following

an itinerary organised by the Service on the basis of the Study requirements outlined by the Project Officer. 1.7.5. Follow-up after the Case Study After each Case Study was completed, a report of the Study was written, based on materials provided, notes taken during the Study and observations made by the Project Officer. This information was analysed in order to inform the Report. Follow-up occurred in order to assist responses by the Service Directors on the draft criteria and the draft evaluation framework.

1.8. Structure of the Report The Report firstly outlines and substantiates the nature of the problem of access, classifying its manifestations, which are then used as recurring themes throughout the report. It then identifies and analyses appropriate responses, structural and practical, which have been developed, and are being practised with success. In these early parts of the report, evidence both written and oral is drawn on. The purpose is to establish and elaborate on the nature of the problem, and to examine responses. These responses to access issues come in the form of government policies and programs, the opinions of current mental health workers, consumers and carers, and models of service drawn up to institutionalise good practice. From these diverse sources, criteria for best practice are identified at a level sufficiently general to be universally valid throughout Australia. These criteria then form the basis of a service self-evaluation tool which is described and presented. Its connections with the earlier exposition of issues and responses are made clear. It is offered as a tool which addresses the barriers to service access identified earlier in the report. It builds on commonly agreed standards of good practice. It has been designed to be easy to use and to be capable of assisting mental health service managers to address problems of access. The report goes on to outline how the evaluation tool was applied on a trial basis in three very different mental health services. The three case studies attempted to gauge the utility and applicability of the tool for each service. At another level, the case studies represent an analysis of services chosen because of their good reputation, so that the project could benefit from an identification and evaluation of good practice in addressing issues of access. The case studies bring together the other elements of the report in dynamic, real-life contexts, as validating and further providing examples of access issues and good practice, and as a test of the applicability and usefulness of the evaluation tool.

Chapter 2 The Access Of People Of NESB To Mental Health Services

2.1. Entitlement of People of NESB to Mental Health Services Government policy in Australia with respect to the provision of public mental health services to severely mentally ill people varies in its detail and emphasis from State to State, and as between the States and the Commonwealth. However, it is united in acknowledging that access to these services should be restricted only on clinical grounds. Where resources are finite, the only determinant for service inclusion should be the kind and severity of the illness, as established by clinical assessment. These policies bear examination, since they constitute statements of entitlement for people of NESB, as for all Australians, and make many references to the specific needs of NESB people. (Australian Health Ministers 1992, Department of Health and Community Care 1996, Department of Human Services 1996, Health Department of Western Australia 1996, New South Wales Ethnic Affairs Commission 1996, Northern Territory Legislative Assembly 1990, South Australian Mental Health Service 1991, Queensland Health Mental Health Branch 1995). 2.1.1. Policy Related to Provision of Mental Health Services for People of NESB Policies of the States and Territories in Australia related to the treatment and care of all severely mentally ill people are articulated in the first instance in the Mental Health Acts of each State and Territory. They are directed to balancing the rights of such people to care and treatment in the least restrictive environment consonant with the severity of the illness, and the rights of the general community to safety. However, these constitute the most formal and specific statement of rights, and are chiefly concerned with ensuring the civil liberties of people who are incarcerated because of severe illness. Other kinds of policy statement issued by governments are much more concerned with principles and practice of service delivery, especially in the burgeoning community-based sector, and outline much more clearly the mandated standards for service access and delivery. 2.1.2. National Policy At the Commonwealth level, the aims of the government are articulated in the National Mental Health Policy (Australian Health Ministers 1992). This was developed by all Health Ministers in Australia in 1992, and specifies ready service access for all Australians as a primary aim. The policy makes special provision for “at-risk” groups, including in these people from non-English speaking backgrounds (p20, 24). The National Mental Health Strategy, a cooperative program between Commonwealth and State governments to improve mental health outcomes for both individuals and for the community from 1992 to 1998, was devised to implement this, and is monitored annually by a National Mental Health Report (Australian Transcultural Mental Health Network 1996). The

most recent of these Reports is the 1995 Report which was published in July 1996, and reports progress against agreed objectives for each State and Territory. The Strategy is funded by the Commonwealth Government at a level of $269m. More recently, National Standards for Mental Health Services have been set. Published in December 1996, these Standards refer specifically to the needs and rights of people of NESB in the delivery of mental health services across Australia, and cover: • Rights • Safety • Consumer and carer participation • Promoting community acceptance • Privacy and confidentiality • Prevention and mental health promotion • Cultural awareness • Integration (ie service integration, integration with the health system and integration with other sectors) • Service development.(Department of Health and Community Care 1996) These Standards, applicable across Australia, allude specifically to the rights of people of NESB suffering severe mental illness to: •

•

have access to accredited interpreters: Standard 1: Rights Standard 7: Cultural Awareness Standard 11: Delivery of Care have sensitivity shown to their cultural needs: Standard 2: Safety Standard 7: Cultural Awareness have access to printed general information in a number of languages Standard 1: Rights Standard 2: Delivery of Care have specific information provided for them Standard 4: Promoting Community Acceptance

As well, all of these Standards govern service delivery to the whole community, and so put the onus most explicitly on services to accommodate the variety of people who make up the Australian population in providing services which are equally accessible to all on the basis of clinically determined need. In a country of many cultures, many languages, services must be as culturally appropriate as they must be appropriate for different age groups, or for the treatment of different disorders. These Standards make clear that the service must accommodate the client; the client should not have to experience disadvantage because of deficiencies in the service. This goes to the heart of the problems which many people of NESB experience in attempting to access services, or being simply unable to do so, because they cannot fit themselves into the mould offered by the services. These Standards appear to offer a guarantee of access. However, it is not clear how they will be financed or communicated or enforced.

2.1.3. State Policies The recognition of special needs of people of NESB who are severely mentally ill differs from State to State, and is articulated by a number of States and Territories. The Victorian Government’s policy is expressed at length in a publication of the Psychiatric Services Branch of the Department of Human Services. This outlines what it considers may be done by service providers to ensure that people of NESB get the same level of service as other Victorians (Department of Human Services 1996). It covers matters related to effective access such as knowing the local community’s composition and gearing services to clients’ needs in terms of language, cultural sensitivity, methods of service delivery and information sharing. It is one of a series of documents outlining the Branch’s overall policy for mental health service delivery. (Department of Health and Community Services 1994, Department of Health and Community Services 1994, Department of Human Services 1996a, Department of Human Services 1996b, Department of Human Services 1996c, Dept. of Human Services 1996d). Queensland’s policy statement is more specific about the actual measures which the government plans to take in response to the NESB population in its bounds. It makes a series of policy statements about: • matching services to needs • training of staff • provision of accessible information • community education liaison and support • client participation in planning • appropriate data collection • explicit service standards • NESB people who may be additionally disadvantaged because of gender, location and previous experience of trauma. It has specific strategies for improving service provision in each of these (Queensland Health Mental Health Branch 1995). South Australia’s Mental Health Policy addresses “Service Provision for a Culturally Diverse Community”. In a Statement of Practice, it sets out guiding principles for service provision and strategies for implementing these principles in the service context. These include: • cross-cultural education of staff • development of staff sensitivity to specific cultural needs • flexibility in service provision • cultural sensitivity in individual psychiatric assessments • management support of culturally sensitive practice • acknowledgement and resolution of cross cultural issues in practice and treatment • consultation with ethnic communities about ways to resolve language and cultural barriers • use of all available linguistic supports • participation in community cross-cultural education and service development (South Australian Mental Health Service 1991)

Western Australia’s policy is one of a series for mental health service clients who have special needs. After describing a general policy of client involvement and effective service delivery, it outlines its main objectives in terms of strategies and key actions for achieving these. These include: • the application of the principles of client participation in service planning • provision of service information in community languages • ready availability of interpreters • effective liaison with community organisations • specialist services for the survivors of torture and trauma • appropriate training for service providers • research into NESB people’s service needs (Health Dept. of Western Australia 1996) The ACT document is very brief, and makes the point that its mental health policy is one of general availability of its services to all who need them. It acknowledges special needs of people of NESB, which are to be met through appropriate staff appointments, interpreter services, literature and staff education (Department of Health and Community Care 1996). The Northern Territory undertakes in its Mental Health and Related Services Policy to “provide culturally specific programs” for migrants and ethnic populations. This is then elaborated in a set of Principles (Northern Territory legislative Assembly). The aim of these principles is “to achieve a culturally appropriate mental health service in the Northern Territory”. They address: • communication - written information in community languages, use of licensed interpreters and translators • services - provision of special clinical team or contact person in each region, and of information about this, as well as culturally sensitive mainstream services • staffing - recruitment of staff with interest and competence in cross-cultural issues; training of staff in interpreter use; cross-cultural education of staff • policies - provision of specialist mental health input (including migrant input) into migrant and refugee health policies • research - foster research to improve migrant mental health status; use existing data for evaluation of programs • programs - implementation of cross-cultural mental health programs • self help networks - foster development of these and of referral networks from GPs, community workers; set up programs for children re promotion, education, prevention • general - regional managers to translate these Principles as appropriate at the local level A NSW policy document is in preparation, and will be complemented by existing documents setting out an Ethnic Action Plan, and a Directory of Services (New South Wales Ethnic Affairs Commission 1996, New South Wales Health Department 1997). Tasmania does not have a formal policy which addresses mental health service delivery principles for people of NESB.

Policy about the access of people of NESB to mental health services when they have a severe mental illness is basically in agreement across Australia, even while the extent and content of articulation varies from State to State. It acknowledges, with the exception of the ACT, that such access is difficult unless supports are put in place, such as language services, information services and educational services for service providers. But it asserts the right of all people in Australia to public mental health services.

2.2

The Nature of the Need

2.2.1. The Migration Experience The nature of the problems involved with limitations on access must be related to the nature of the migration experience, and the ways in which this experience can heighten a person’s vulnerability to severe mental illness. This will vary greatly from individual to individual, but research indicates that some characteristics of this experience may initiate or enhance mental illness in the migrant. These characteristics include: • low and/or reduced socioeconomic status • low educational status • unemployment in the new country • language difficulties • separation from family • migrating in old age • lack of recognition of work or academic qualifications • cultural isolation • the experience of torture, trauma and related stress prior to migration • difficulty in adjusting to the new country • experience of prejudice and discrimination in the new country (Minas et al 1996, Losaria-Barwick & Durbin 1991, Minas et al 1995, Fellin & Powell 1988, Minas et al 1994) The relationship between cause and effect in these characteristics is as variable as the numbers of migrants experiencing mental illness, and their individual and unique experience of migration. It would also seem no more firmly established than in the case of any serious mental illness. Clinician, carer and client may hypothesise from their different perspectives about the “cause” of the illness, but cannot confidently ascribe the relative roles of genetics, catastrophic experiences, personality and exposure to harmful substances. The principal “proofs” offered in the literature are often based on inference from association of migration and mental illness, on statistical analyses which do not invoke personal histories, or, on the other hand, studies which are so specific it is difficult to extrapolate from them to more general observations. Service utilisation data alone can show something of which ethnic and age groups gain access to services in particular areas. However it leaves unanswered the relationship between the migration experience and mental illness, the questions of actual service need, of why one kind of service (eg GPs, or attendance at hospital emergency departments) may be preferred. It also does not explain why service access may not be achieved. Regardless of the nature of the connection between migration and mental illness, those who have had the former experience may have added vulnerability to the latter.

2.2.2. Refugees and Their Need for Mental Health Services A refugee is a person who, owing to a well founded fear of being persecuted for reasons of race, religion, opinion, is outside the country of his (or her) nationality, and is unable, or owing to such fear, is unwilling to avail himself (or herself) of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable, or owing to such fear, is unwilling to return to it (Minas 1997). There is a particular group of migrants whose circumstances of migration can be more certainly linked with subsequent mental illness. Some migrants to Australia have come here in circumstances of great disruption, loss, and suffering. Refugees may have been forced to flee their homeland because of war or political oppression. They may have lived in holding camps for months or years, uncertain of their future. They may know little of the country to which they come. They are in a very different position from migrants who have actively sought the opportunity to come to Australia. It has now been established that 60-80% of refugees have physical and mental health problems related directly to torture experiences or associated refugee related trauma (Aristotle, 1995). This persecution covers a broad spectrum of traumatic experiences. Aristotle, the Director of the Victorian Foundation for Survivors of Torture, categorises them according to severity in three levels: • extreme and sustained experiences of torture; • moderate experience of torture; • oppressive practices which create trauma. He cites research showing that “up to 30% of humanitarian program migrants have suffered from severe forms of torture”, and that a further 50% have experienced oppression which constitutes torture, albeit of a lower severity (Aristotle, 1995). These migrants experience the ill-effects of migration listed above to a much greater degree than voluntary migrants, and they may continue to suffer for decades after arrival in Australia. Aristotle argues that, because of their experiences, refugees are at once more vulnerable to severe mental illness, and unable to gain access to the services they need because they are traumatised, distrustful of officialdom, and unfamiliar with English. Even where there has been no personal experience of torture, the trauma and deprivations experienced by refugees in their countries of origin make them vulnerable indeed to mental illness. An African psychiatric nurse working in Melbourne’s northern suburbs, Francis Acquah, has researched the plight of refugees now living in Melbourne who have come from Somalia, Eritrea and Ethiopia. They have fled war and famine. They have spent time in refugee camps. Some have been directly tortured. Acquah lists the problems they now experience following these experiences as “symptoms of anxiety, headaches, alteration in sleep patterns, behavioral disturbances, depression, aggression, feelings of powerlessness, alienation, isolation, loneliness, difficulty in establishing and maintaining relationships and reduced levels of self-confidence and self-esteem.”

(Acquah 1994) Whilst this account includes a wide range of disturbances, Acquah cites admission data from Royal Park Psychiatric Hospital which indicates that the most severe mental illnesses are also occurring with this refugee group. Referring to women from these Horn of Africa countries, Acquah also points out that these refugees tend to be illiterate or barely literate in their own languages, making it difficult for them to learn English and to gain employment and access to the services they need (Acquah et al 1993). 2.2.3. Entitlement and Need: Summary The need for mental health services for people of NESB who have migrated to Australia is at least that of English-speaking people, and likely with many to be greater. Many migrants who are not comfortable communicating in English experience severe mental illness, to a greater extent on the whole than people from the dominant Anglo-Celtic culture (Minas et al 1995). When they are ill, they often do not receive the services they need in a timely, acceptable and effective way (Minas et al 1995, Velanovski 1996). Because they do not, they can be said to have inadequate access to public services to which they are explicitly entitled in terms of government policies. Reasons for this diminished access must be explored and understood before solutions can be proposed.

2.3. Barriers to Service Access Barriers to mental health service access for people of NESB fall into two broad categories, which reflect, firstly, characteristics, knowledge and behaviour of NESB people mediated through their specific culture, and, secondly, the culture of mental health services and the knowledge and behaviour of service providers. Perceptions held by NESB people about mental illness, about the significance of symptoms, about desirable patterns of care, about the role of health workers are often not shared by those workers, and so either services are not sought, or, being sought, cannot be satisfactorily accessed. However, while both people of NESB and service providers alike, the responsibility for ensuring access is that of the service provider. This is made abundantly clear in the policies developed by Australian Governments at Commonwealth, State and Territory levels and outlined above. In the following chapters, the report will, firstly, identify and explore these barriers within the categories in which they present in real life. They include: Language; Lack of appropriate information; Poor communication; Stigma; and Cultural differences between client and clinician. These will be the five major themes through which the report will • explore the issues contributing to poor access, • describe current practices designed to address and rectify these issues, • describe and analyse models which have been devised for the same purpose, and • present and apply an evaluation tool which service managers may use to improve access in these four areas.

2.3.1. Language The biggest barrier to effective service delivery is considered to be language. The Canadian Task Force investigating mental health issues for people of NESB noted that lack of a common language between clinician and client is the biggest obstacle to accurate assessment (The Canadian Task Force on Mental Health Issues Affecting Immigrants and Refugees 1988). Minas et al in 1994 made a study of the language skills of mental health service providers in Victoria. The study demonstrates the difficulties which the NESB person experiences in locating the service, in communicating with clinicians and in gaining an accurate diagnosis of and appropriate treatment for their illness (Minas et al 1994). Even where service staff have competence in a language other than English (14% in Victoria, as indicated in the Minas, et al study) the chances of these competencies being matched to client need are low in an environment where no structures exist to ensure this. An Ethnic Mental Health Consultant in Melbourne’s Western Region, Stolk, has examined this issue in the context of this region, where NESB numbers are high. Her conclusions support the Minas study’s findings that there is a poor match between need and availability of language skills. Since her study, however, a number of Vietnamese bilingual workers are now employed in this area, eg at the Mid-West Area Mental Health Centre (Stolk 1996). At the client-worker level, the consultation and Case Studies bring up some of the complexity and diversity in the way the language barrier is experienced. Some people of NESB showed a decided preference to be treated by a clinician who spoke their language. *A bilingual psychologist working in the public mental health service system, also contributes considerably to policy and program development. She has acquired a caseload of clients who wish to retain her as their primary source of treatment, even where another service worker of another discipline is engaged in the role of case manager. *A bilingual worker in a non-government organisation has seen many older people of European origin who have migrated to Australia decades ago. As they age, their mastery of English deteriorates, and they are prone to become very depressed, homesick for another place and time, and find it difficult to relate to young clinicians, and impossible to relate to any clinician who does not speak their primary language. *A Latin American mental health worker was most definite that the chief difficulty for his countrymen in gaining access to mental health services was language. Their lack of knowledge of English told against them at every turn, hindering access to information about services about locations, about their entitlements, about mental illness itself and creating the sense of isolation and powerlessness which this worker saw closely linked with the depression experienced by a number of them. *A young woman of European origin who herself experiences a dual mental disorder has worked extensively with other “consumers” of mental health services. She believes

that many migrants who may have a working everyday knowledge of English are nonetheless overwhelmed by medical terminology when they seek services. They do not seem to need interpreters, and are not provided with them. They are too proud of their command of English to request them, and may be afraid of encountering someone from within their community in this role. The outcome, she claims, is poor communication, and poor effective service access. In another instance, the clinician’s culture seemed irrelevant when the symptoms of schizophrenia were overwhelming. However, when medication had assisted recovery somewhat, it became very important that the person understood what the clinician was trying to communicate. *A young mother of NESB explained that when the symptoms of her schizophrenia were particularly bad, it made no difference to her whether clinicians spoke to her in her own language or in English (which she speaks only with hesitation). She pointed out that the main source of assistance to her was the medication, and that the kindness shown to her in hospital by English-speaking nurses knew no language barriers. However, when she was somewhat recovered, and attending the local community mental health centre, she found it very frustrating that no one there spoke her language, and that no attempt was made to obtain an interpreter’s services. It may be that in circumstances where the client feels overwhelmed by illness, medication speaks louder than language, though this begs the question of correct diagnosis. It may also be that the relationship of trust with a particular worker developed and carefully nurtured over months, in the context of a supportive service environment, with the presence of a qualified and competent interpreter can overcome the language barrier. In the absence of these added elements, and in a circumstance where the encounter was a “first”, the wish to have a same-language clinician would understandably be stronger. This discussion of the kind of barrier presented by language serves to underline the dangers of making simplistic assumptions about how this barrier is experienced by mentally ill people of NESB. Certainly there was no common viewpoint beyond the need for clinicians to ascertain the need experienced by the client in any situation, and to have the cultural understanding, the time and the interpreter resources to meet that need. 2.3.2. Lack of Appropriate Information Lack of appropriate information about the nature of mental illness, the significance of symptoms, the location of services, and the processes of entry into services and of referral, acts as a powerful impediment to people of NESB in gaining timely and appropriate access to mental health services in Australia. Services and individual clinicians can also lack information necessary for the provision of a good service, such as demographic information about the population of their service catchment area, cultural information, information about interpreter services and how to use them, about local community organisations and how to access their knowledge.

This problem is closely interwoven with the barrier created by language. When Denis conducted a bilingual psychiatric program with Croatian-speaking people in Queensland, she observed that community education and information dissemination campaigns are carried out in English only. At that time (1994) the only information available in Croatian in Queensland relating to mental health services and about mental illness was developed in New South Wales. The material relating to the nature of mental illness was appropriate enough. However, service system information in Australia is highly local and specific, and could only serve to confuse (Denis 1994). *A manager at an ethnic community centre had no information about local mental health services, in English or in the major community language. He had not been provided with information about their structure, organisation, referral practices, and felt unable to refer clients in a comfortable way. As this person was clearly the conduit to many community and health services for the many people of NESB who attended the centre, the lack of information about local mental health services was a formidable barrier to service access for these people. This manager was decidedly unflattering about the local GPs of the same ethnic group in terms of their willingness to provide information or services related to mental health, seeing them as a positive hindrance to good mental health service provision. *Other ethnic workers interviewed were also of the view that lack of information for people unfamiliar with English about services and the nature of the illness is widespread and constitutes a decisive barrier to service access. One gave a moving account of men isolated by language, pride and lack of information, calling strongly for education and information in their own language. *Women who had recently arrived in Australia felt equally isolated, experiencing compounded problems related to gender, language, lack of access to family members and culturally specific negative perceptions of mental illness. In 1994, a study of women of NESB in Melbourne’s northern suburbs was carried out. It found that the more recent the arrival and the poorer the English of the NESB woman, the less likely they were to have the wide social and familial supports which can assist access to information about services (North East Women’s Health Service 1994). An Ethnic Health Audit performed within a government funded community service organisation in 1996 found that lack of understanding about what the organisation could do for NESB people, that is, lack of information, was one of three major identified problems blocking appropriate referral and access to the organisation (Velanovski 1996). That lack of information for local people of NESB was indeed a problem for them in gaining access to this service was borne out by the fact that of 308 clients on the books at the time of the Audit, only four were uncomfortable with English. This was in an inner northern area of Melbourne, where people of NESB are highly represented in the population. A recent report, commissioned by the Department of Social Security addressed this problem of ‘Determining Best Practice in Information Provision to People of Diverse

Cultural and Linguistic Backgrounds’ in a qualitative report published in 1997. In defining “best practice” in providing information, the report asserts three essential characteristics: • Defining the audience, and understanding its receptivity to a particular message in terms of its willingness to listen to and ability to hear the message • Determining the content of the message in terms of its interest to the audience, of whether the audience is ready for it, or whether the audience is likely to resist it • The range of information dissemination strategies in terms of capacity for individual and networks approaches (Australian Transcultural Mental Health Network 1997). Printing information in community language leaflets seems to be the most common response to this problem of lack of information about services and about the nature of mental illness. However, it is not a strategy aimed at a specific audience, but rather at a most heterogeneous group of people whose sole defining characteristic is that they do not speak, or are not comfortable with English. So, in terms of the principles outlined above, it would warrant widespread use only in conjunction with other activities much more targeted and understood. At the three services where Case Studies were carried out, there were such pamphlets displayed and available free of charge in waiting areas. No clients were observed taking them or showing any interest in the stand where they were displayed. No workers were observed giving them to NESB clients as part of therapeutic interaction, even where the client was being seen for the first time, an interpreter was being used and the client clearly did not know much about the range of services available. *A person who had lived in a war zone for five years, and now experiencing extreme anxiety, was interviewed by a psychiatrist in a community mental health service, using an interpreter in order that she could be assessed for appropriate treatment. A community worker who accompanied her indicated that she was travelling a long way to the GP, who did not speak her language. She was clearly fearful of attending the mental health service, and indicated strongly that she would like to attend a GP who speaks her language. This was arranged. In this encounter, information pamphlets about the service, and explaining her illness were not given to her, even though she was clearly literate, with tertiary qualifications. Two points emerge from this. Firstly, this person had not responded to the pamphlets in the waiting room, even though they were well displayed, available in her language, and she needed information. Secondly, it did not seem to occur to the very caring staff involved in this encounter to use the pamphlets as an adjunct to their clinical work. This suggests that translations of information need to be accompanied by a clear strategy for their use, and that perhaps a specific staff member, such as the receptionist, could point them out. 2.3.3. Poor Communication as a Barrier to Access Barriers of understanding do not stop at language and literacy. The methods by which a mental health service communicates –or fails to communicate – the causes and meaning of mental illness may prevent people unfamiliar with English from benefiting

in any way from printed information, even if they are sufficiently literate in their own language to read them. *An ethnic education worker is of the strong view that both education and information provision should take place where people actually meet and congregate, at the most grass roots level, where true communication can take place. Yet, if they occur at all, they are most likely to be held at “official” premises, as in the instance cited above, to be formal, and to assume literacy. There was general agreement amongst those interviewed for this project that information about locally available mental health services should be much more widely disseminated in the whole community. For people of NESB, many venues would be suitable for mental health service workers to attend, with an interpreter, to explain about mental illness, what to look for, and how to access help from services. These include : • local radio stations • community groups’ meeting places • maternal and child health centres • GP surgeries • community health centres • local service and sporting clubs and • private homes. People do want to know, and they have the right to know. If Area Mental Health Services are to be effective, they must be “owned” by their community, and this must mean informing that community, in all its diversity, about their services and activities. *The manager of an ethnic health organisation felt strongly that the attitude of service providers to ensuring adequate communication about the service is all too often that of “take it or leave it”. This, she believes, is a total abrogation of professional responsibility to adapt services to people’s needs. She pointed out that it is part of the brief of community mental health services to provide services to the most severely mentally ill in the community. They can only do this if all of their community is adequately informed, so that those in need of care and treatment can be identified. Otherwise, access and treatment becomes a matter of chance. Communication methods must take account of the fact that many people of NESB have very different interpretations of and reactions to the symptoms of severe mental illness from Australian-born people. An Ethnic Health Audit conducted at Royal Park Hospital in Victoria recorded some of the reactions of people of NESB who did not understand why they had been hospitalised. They attributed their problems to other causes and had to deal with family members who did not consider they were ill (Ethnic Advisory Committee of Royal Park 1994). 2.3.4. Stigma as a Deterrent to Seeking Assistance from Services An excellent Implementation Plan was devised to apply the findings of the Canadian NESB Mental Health Report to the needs of the city of Toronto. Its authors note that

people who do not share Western medical assumptions about causes of and treatments for illness will not then seek help from government clinics, but are more likely to look to their own cultural sources of support. However, they also cite an example of the barrier created by “non-Western beliefs about the causes of illness and methods of care”. This is the extreme stigma and shame attached to mental illness in some communities (The Canadian Task Force on Mental Health Issues Affecting Immigrants and Refugees 1988, Losaria-Barwick & Durbin 1991). Thus the sufferer, or the sufferer and the family together, may experience a uniquely compounded isolation. Not only have the bizarre symptoms of mental illness rendered them frightened and distressed, but they then become pariahs within their own community, and doubt the efficacy of the Western alternative. Even where the community belief is in a westernised medical model, the family does not trust the Australian services to deliver effective treatment, or to maintain confidentiality. This fear of rejection and stigmatisation associated with mental illness is not restricted to people of NESB. The rationale for general public education campaigns in Australia about mental illness is that it does engender fear and the shunning of sufferers, even with people who accept a western medical model. However, this is heightened in people who have a different world view, and for whom the epistemology of mental illness is spiritual. Psychiatric nurse Francis Acquah remembers from his childhood in Ghana traditional beliefs attaching to mental illness. An ancestor’s spirit may have been angered, a witch may have cast a spell, a ghost may have been exercising malign powers. For whatever of these reasons, people who were “mad” had to be isolated and incarcerated in the “Asylum” so that others might not be similarly afflicted (Acquah 1994). The effects of this pervasive feeling of deep shame about mental illness in the family are that services may not be sought until illness is acute. *A Vietnamese community centre manager in Melbourne spoke of the tendency of Vietnamese people to demonstrate mental illness as physical illness because of deep shame felt by them about mental illness. He described a service context where Vietnamese GPs did not want to have to deal with mentally ill people for fear of being stigmatised in the eyes of the Vietnamese community and where local community mental health services had not communicated information about their services to the Vietnamese community. In this situation, families coped as best they could, until a grave emergency occurred, when they would present at a casualty department in a major hospital. In the course of the consultation carried out for this project, there was not one dissenting voice on this issue. To have a severe mental illness, or to have a family member with one, was to experience stigma, distancing, isolation. 2.3.5. Cultural Differences Between Client and Clinician *A young woman who had developed schizophrenia since her marriage, but who was managing well at home with medical and social support, had effectively lost access to her two children because her husband’s family thought her to be “mad”. She leads a

quiet life in an immaculately tidy house, seeing her children only under her husband’s supervision once a week. *A young Indonesian woman who is Muslim experienced a severe mental illness. She was convinced that her baby daughter had to be circumcised, but the American father of the baby strongly objected. The worker was able to access an Imam in the community to counsel the young woman that this operation was not necessary, and another worker with a knowledge of the Q’ran discussed with the young woman its implications for this situation. These combined supports for the young woman gave her grounds to change her mind about the circumcision. At the same time, her health improved as she was no longer faced with what, to her, was a major dilemma. Minas points out that cultural assumptions are complex, and shape the individual’s views of the self and the world in ways which influence every aspect of behaviour and belief. Moreover, whilst the individual believes, thinks and acts within a cultural framework, this does not make culture deterministic. Culture informs and shapes, but the individual is still an individual (Minas 1997). Thus each person confronted with symptoms of mental illness will have a framework of reference within which it may be understood, and there will be a usual, even a common, response from others of the same culture. However, this does not mean that a person can understand and be understood through the provision of service responses tailored by standardising or stereotyping. The response must be to the person, but that response must be informed by cultural understanding. When those of the same culture are rejecting the ill person, or offering alternatives which may be comforting but are essentially ineffectual, when those who can offer treatment and respite from symptoms do not understand the ill person’s culture, the chances of access to treatment are small indeed. And if they do seek mainstream mental services, their access to effective treatment can only be successful if differences in what Lin terms “health belief systems” are acknowledged and dealt with (Lin 1990). Culture is equally critical and complex in the context of service provision. Lack of information about mental health services coupled with language difficulties, shame, stigma and prejudice are powerful deterrents to mentally ill people of NESB seeking mental health services. However, the service providers themselves work within an environment where assumptions about causes of illness and efficacy of treatments form part of a medical culture which is never questioned from within, and where preparedness to accommodate alternative cultural paradigms is by no means assured, or even seen as necessary. In the US, Lewis-Fernandez and his colleagues considered the cultural, clinical and research issues involved in practising effective psychiatry with cultural sensitivity. They point out that the positivistic and culturally bound assumptions of western science are not appropriate or indeed adequate in the context of treating mental illness in someone of a different culture. They point out that culture impacts on mental illness at every level, in terms of cause, course, treatment and outcome, and will affect symptoms, willingness to seek assistance, communication with the health service provider and compliance with proposed treatment. Developments in anthropologists’ and historians’ understanding of the meaning of culture, and of the rich social and physical textures

which comprise it, have informed, or should have informed the practice of psychiatry (Lewis-Fernandez & Kleinman 1995). A major sticking point has been the overwhelmingly positivistic orientation of the earlier editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), in spite of evidence that the signs and symptoms of the major mental illnesses described are not easily applicable to other cultures. This orientation was not much altered in the Manual’s most recent and eagerly awaited fourth Edition, DSM-IV, in spite of expert advice on appropriate modifications. This is seen as a major failure in the development of culturally relevant psychiatry in recent times, because of the extraordinarily influential nature of the Manual. Another major deficiency is seen to be the remoteness and inaccessibility of psychiatry for most people, particularly for people in or from the developing world. This inaccessibility is likely to be replicated if a migrant from such a country migrates to Australia, albeit for quite different reasons based on incomprehension and fear (LewisFernandez & Kleinman 1995). Minas echoes these concerns, pointing out the practical consequences for the efficacy of clinical intervention where the service provider is ignorant of the client’s culture, and of his or her own culturally bound and limited response (Minas et al 1996). The discrepancy between how the person of NESB experiences mental illness, and how a clinician views that person, creates significant barriers to effective treatment. Writing from the perspective of a psychiatrist working in a mobile crisis mental health team in New York, Thomas Chiu discusses four psychiatric patients of NESB from very different cultural backgrounds receiving care and treatment in the community (Chiu 1994). In all cases, progress with the patient’s treatment could not be made until the team stood aside from a purely medical perspective and identified cultural issues which were barriers to effective treatment. These barriers were incomprehensible unless cultural understanding was gained. A Jewish man failed to take his medication in spite of apparent compliance. The reason? The pills did not meet the criteria for being kosher. A mainland Chinese woman denied her illness, but was prepared to accept medicine in the context of more general assistance with housing. An Hispanic man who had suffered from recurring psychoses for years, found it necessary to demonstrate physical violence and abuse before he could accept medication, in order to satisfy the unspoken requirements of his culture for a man to manifest “machismo”. A British study comparing rates of admission of children and adolescents of Asian and Caucasian origin to mental health services shows a much lower presentation level of the Asian children, and concludes that cultural norms preclude ready access of these children to services (Roberts & Cawthorpe 1995). Other US studies document in detail the experiences of clients from minority cultures attempting to obtain successful care and treatment from Western-oriented services, and the gulf in assumptions on both sides which exist (Rosado 1980, Chiu 1994, Lin 1990). Australian studies likewise observe that stigma and fear of rejection and misunderstanding constitute powerful barriers to access to the successful treatment of mental illness for people of NESB (Department of Health and Family Services 1996, Sozomenou et al 1997). In her evaluation of the impact made by the appointment of a Vietnamese Case Manager in an area of Melbourne with a high Vietnamese population, Stolk noted a very serious degree of illness in those who did attend services, suggesting unwillingness to use

them unless desperate. The under-representation of non-psychotic disorders, of those aged under 25 and over 40 suggests a significant level of unmet need in the Vietnamese community with possible implications for family burden. This perception is reinforced by a marked increase in unregistered contacts relating to the Vietnamese community following the commencement of the Vietnamese Case Manager (VCM). In turn, this suggests that the barrier to access may be gradually diminishing as knowledge of the VCM’s position becomes more widespread (Stolk 1996). Cultural gulfs between service providers and their clients can also have the opposite effect, where instead of underutilising services, the clients may instead press for an undue level of service in the fear that otherwise they may miss out. A United States study of elderly Russian emigres outlines the pressures on the service system where these people made excessive demands because of their homeland experience of scarcity (Brod & Heurtin-Roberts 1992). Closer to home, however, Stolk concludes that the low utilisation rate by Vietnamese migrants in the Western area of Melbourne relates to the stigma attached to mental illness in that culture (Stolk 1996). A bilingual health worker working with the Croatian community in Queensland found this same problem, and focused on community education aimed at informing and educating the Croatian community in order to change the stigma and prejudice with which they regard mental illness (Denis 1994). The lack of match between Australian mental health services and the cultural understandings of many of their NESB clients was mentioned frequently in the project consultation. *A Columbian GP saw the conflict at a number of levels. The culture in the services, he believes, is essentially corporate and non-reflective. As such, services tend to be oriented to providing standard services rather than to matching the resources of the service to individual client needs. Service providers tend to be unaware of their own service culture, and of three important levels of interaction between a client’s culture and her mental illness: • culture as constructing mental illness • culture as producing mental illness • culture as an essential basis for understanding mental illness. *Such lack of basic understanding has led to many inappropriate inpatient admissions, maintains a psychiatric nurse. He spoke of an initiative within more settled and highly educated African communities in Melbourne to establish a multinational African panel of people who could provide intervention, support and “cultural translation” in crisis situations. *A community mental health worker treating a young Greek man found that efforts of the treating team were continually undermined and opposed by the man’s family. At the time of interview, the team was considering its options for nullifying what it had come to regard seriously as the life threatening behaviour of his family. Twice the family had returned with the young man to Greece for treatment. Twice he had returned unwell and needing emergency admission to hospital. Negotiations to achieve a middle

ground and to accommodate their anxieties had proved fruitless. When asked to identify their difficulties in providing good services to people of NESB, staff at the North Eastern Alliance for the Mentally Ill in inner suburban Melbourne cited the following: • different cultural background from client - harder to understand what is normal (sic) for that culture • dilemma as to whether barriers in communication are because of culture, language or mental state • NESB clients unwilling to attend cultural programs • communication (as distinct from language differences). The Director of an ethnic health centre, consulting with people of NESB about the appropriateness of the Centre’s Services, concluded that cultural relevance and appropriateness need to become a central concern of all service providers, planners, policy makers and funding bodies. As well, there needs to be a recognition that specific strategies targeting particular groups are an integral part of any quality service, not an ‘optional extra’ (Victorian Department of Health and Community Services 1995). 2.3.6. Conclusion The barriers to access to mental health services for people of NESB are complex. They relate to the disjunction between the service provider’s culture and that of the client. They are to do with problems of language and the availability of bilingual staff and/or appropriate interpreters. They arise out of systems of health delivery which take little account of cultural diversity and operate on diminishing budgets with an increasing emphasis on treating very ill people in the community. They go beyond the formidable barrier of language. Minas sees the problem as: • in the exclusion of the client from the service development process, • poor education of service planners, • paucity of research related to the epidemiology of mental illness in NESB communities and • the lack of culturally appropriate and therefore more effective models of service provision (Minas et al 1996). Appropriate models for better access and service delivery for people of NESB are the bridge between the politically correct policy documents which can be misleading if taken for description rather than prescription, and the busy mental health worker delivering direct care. What shape does the “good” service have? What structures allow innovation, initiative and commitment to the individual client? What interplay of service principles and service structure allow maximum scope for best practice in transcultural psychiatry? And how are principles of good practice found to work in the clinical setting? These questions, critical to the matter of improved access for people of NESB, are now considered.

Chapter 3 Identifying Effective Approaches To Increasing Access In this chapter, the five themes of - Language; Information Provision; Communication; Stigma; and Cultural sensitivity. will be explored in the context of identifying solutions to existing barriers to access to mental health services for people of NESB. This will be done in two different contexts: • models which have been developed to address these problems of lack of access • current practices in Australia and elsewhere which serve to improve this access.

3.1. Models of Best Practice Models relating to achieving better access to metal health services for people of NESB have been developed both as comprehensive statements of criteria for best practice and as statements of principle in the course of addressing specific access issues. In this chapter, a number of models developed over the past decade, most of them in Australia, are considered, in order to discover their common themes, their emphases, and to relate them to the issues for NESB people so far identified. 3.1.1. A Canadian Model An excellent model was developed in the early 90s in Canada. This was the response made by Losaria-Barwick and Durbin to the Canadian Government Report on mental health service delivery in Canada to people of NESB (Losaria-Barwick & Durbin J 1991, The Canadian Task Force on Mental Health Issues Affecting Immigrants and Refugees 1988). The Government Task Force recommended four priority areas for funding which it believed would have the best potential for improving NESB people’s access to mental health services. Firstly, information on available mental health services should be developed and made available multilingually, thus addressing the language barrier. Secondly, a training program for interpreters to work in mental health services should be developed. This was to assist cultural understanding, including the significant role of stigma. Thirdly, immigrant service agencies should employ mental health workers. This would facilitate the provision of accurate information about mental illness and about the service provision system. It would also improve communication between ethnic services and mental health services. Fourthly, ethno-specific mental health rehabilitation and reintegration facilities should be funded, so that treatment would be culturally specific and therefore most effective (The Canadian Task Force on Mental Health Issues Affecting Immigrants and Refugees). These recommendations were translated into a program by Losaria-Barwick and Durbin (Losaria-Barwick & Durbin 1991).

These writers argued that the development of culturally appropriate programs and services depend upon effective communication, cultural awareness, and appropriate models of service delivery. Effective communication must go beyond the mere provision of interpreters or bilingual workers, and focus on appropriate training for and support of these and other workers. Training is also critical in instilling cultural sensitivity in workers, who must build productive relationships with the community organisations which will assist in the support of clients. In examining structures of appropriate service delivery, Losaria-Barwick and Durbin outline five. These are: • • • • •

Stand-alone ethno-specific mental health programs, where an agency provides services for a specific ethnic community; Ethno-specific programs delivered within existing mental health facilities; Ethno-specific mental health programs delivered in existing health and social service facilities; Mental health care delivered by immigrant-serving agencies; Consultation/liaison organisations

However, they do not suggest that one of these structures is necessarily the best. Their approach assumes the existence of or necessity for a range of structures, and their concern is to explicate principles for excellence. To assist in the challenge of determining the most appropriate service delivery model in a specific instance, indicators of relevance are offered, both general ones and those particular to mental health which cover facts about the community to be served. [P14]. These indicators are: • • • • • • •

size of community; proportion of recent newcomers and second generation people; official language skills; predominant values and beliefs about family, community, role of men and women; demographics- proportion of seniors, adolescents, single parent women, single men; level of organisation - existing social services, cultural groups, recreational clubs, religious organisations etc; socio-economic indicators - levels of education, occupational range, average incomes.

Specific indicators relate to mental health: • • • • • •

extent of existing community mental health services; presence of licensed mental health and health professionals; community beliefs about mental illness and mental health care; help-seeking patterns; alternative community sources used to manage mental illness; eg community elders and healers, herbal remedies; high risk groups or problems; refugees, isolated women etc

They conclude this discussion of the process of choosing models of service delivery by outlining the general principles to guide the process. These are: • cultural and geographic relevance • linguistic relevance • building on existing patterns of service use • offering a range of options • emphasis on community education and outreach • collaboration between minority and general community resources • community participation • adequate funding. At a broader level, in planning for the mental health service delivery needs of a whole NESB population, these authors specify eleven critical areas to be addressed in the planning process. These go beyond the specific area of access to services which is the subject of this report, but do address the five themes identified as critical to improving access to services, ie Language, Information, Communicatio, Stigma, and, Cultural differences between client and clinician. The eleven critical areas identified by the Canadian researchers are: • Identification of those needing services; • Treatment and crisis support so that culturally sensitive and appropriate diagnostic evaluation, supportive counselling, therapy, medication management and crisis assistance are provided; • Availability, and actual use of, highly trained professionals for consultation by a wide range of workers likely to encounter people of need; • Coordination of mental health and related services; • Residential support offering a range of culturally appropriate housing options; • Case coordination and management in ways that meet the needs of culturally and racially diverse consumers; • Social support which takes account of and meets the needs of migrants who may have lost or be separated from family, and who may have a greater identification with their ethnic group than other mentally ill people; • A range of culturally sensitive vocational services and employment options; • Assistance with self-help or peer support which utilises the person’s community networks; • Recognition of and encouragement for family support; • Mechanisms for ensuring advocacy for all ethnic groups in the community. They outline the principle to be adhered to in each case, identify the issues to be taken into account, and outline strategies for success. Clearly, these eleven areas in which best practice with people of NESB should be achieved are just those same areas in which all mental health services should perform well for the entire community. This is a very relevant, thoughtful and clearly mapped out discussion of how to proceed in planning new mental health services. It would be equally useful in assessing existing ones with a view to development and improvement, and its approach is reflected in a number of models of best practice in providing access to mental health services for people of NESB which have been developed in Australia.

3.1.2. Some Australian Models of Best Practice 3.1.2.1. The ADEC Model The challenge of articulating responses to the problems of access has been taken up in the Australian context by academics, service practitioners and community organisations. Action on Disability within Ethnic Communities (ADEC) has published three reports on developing, implementing and evaluating accessible services for people of NESB who have a disability (Fitch et al 1992; Papanicolaou 1994a; Papanicolaou 1994b). While the model was developed to apply to disabilities generally, nevertheless it applies to mental health services. It stipulates that accessibility of services will only be achieved if the organisation is developed for this purpose, and responsibility for accessibility lies with the organisation as a whole. Minority groups of clients must not be marginalised; there must be diversity and integration in program design and the removal of obvious barriers to access. Translation for applicability of these principles to service provision is spelled out in detail without being prescriptive or narrow. It provides excellent recommendations for a range of practical steps to be taken to ensure a user-friendly service environment for people of NESB in any organisation, regardless of structure or size (Fitch et al 1992; Papanicolaou 1994a). The ADEC Model for promoting service accessibility for NESB people identifies four essential service features: 1. making service needs of minority and disadvantaged people a priority 2. allocating to management responsibility for ensuring access 3. diversifying services and programs to accommodate client needs 4. removing actual barriers to NESB participation in services For services to achieve these goals, the ADEC Model focuses on seven service components: 1. Service location and contact - the service can be easily located by NESB people, and information about it is readily available on contact 2. Assessment of service needs of local NESB communities 3. Provision of service information to local NESB communities 4. Internal information systems which include data on NESB clients 5. Program design for culturally relevant services 6. Appropriate staff and work policies and practices promoting best practice withNESB people 7. Consumer participation in service development processes (Papanicolaou 1992). This model both affirms the nature of the barriers to service access for people of NESB in Australia, and offers principles for service development which address the problematic areas of language, information, communication, stigma and cultural relevance. These principles are compatible with government policies for optimising service access referred to in Chapter 2. Their uptake was not in the specific area of mental health services access, but was designed to be in the general disability services sector in Victoria. This may help to explain why they have not been directly applied in the psychiatric services sector Australia-wide.

3.1.2.2. The Minas Model The extensive work of Minas and his colleagues has also focused on what is required to address the problems of access to mental health services for people of NESB in the Australian context. The challenge of providing bilingual support for mental health services is addressed in great detail in a work devoted solely to this issue in response to a Victorian Government policy document (Department of Human Services 1996a, Minas et al 1995). Minas and his colleagues identify five levels at which cross-cultural and interpreter support is needed: • In the direct provision of services • As support to mainstream agencies and professionals providing direct services • As support to families and carers of people with a mental illness, and to their communities • Support to policy makers, service planners and agency managers • National Program development (Minas et al 1995) Minas’ most comprehensive work addressing the problems identified for people of NESB in gaining access to effective mental health services was published in 1996 (Minas et al 1996). This work considers the nature of Australia’s NESB population, the problems of assessing their mental health needs and some of the reasons why their use of services does not reflect their needs for these services. It then examines the broad context of policy and culture within which Australian mental health services have developed, and proposes a range of essential service components. Models for mental health service delivery of the direct service provision type outlined above are then critically examined. These include: • The multicultural psychiatric centre model. This provides direct mental health services, consultancy services to professionals and community groups, liaison with community services and groups and research and education. The centre examined demonstrated high acceptance by the NESB community as indicated by low dropout and high utilisation rates. • ADEC. This is described above. A subsequent evaluation of this Model maintained that a national survey of disability organisations funded by the federal Department of Health showed that 40% of organisations had experienced raised awareness of the model and 24% were actively using it for planning. At the state level (Victoria) 26% had implemented it and 33% were working on implementation (Papanicolaou 1994). • Community mental health clinic. This model provides clinical treatment, consultancy education and liaison. Minas considers two examples of this model. • Clinic specifically for needs of survivors of torture and trauma. Minas considers three examples of this model. • Bilingual Community Mental Health Teams. These would be suited to larger ethnic communities, and would form part of a Community Mental Health Clinic, directing the team’s services to one ethnic group. • Collaborative models featuring liaison between public and private health workers to achieve better service coordination. This work brings together in a program for change his concerns articulated in earlier writings and his proposals for improving mental health service delivery for people of

NESB in Australia (Minas 1992, Minas et al 1993, Minas et al 1994, Minas et al 1995). However, it looks at models in terms of different structures, rather than in terms of universally applicable principles or criteria for best practice. A more informal and principle-based summary of Minas’ criteria for good mental health service provision to people of NESB lists six: • accessible information about the service • adequate access to the service eg economic, geographic • ability to convince potential clients that the service is appropriate to their needs, that workers will take their needs seriously and respond to them in the client’s terms • good quality of treatment outcomes • programs developed in response to identified actual needs • best use of available linguistic supports (Vietnamese Community in Australia, South Australian Chapter 1993). These six criteria match well with the themes identified as important in the current study – those of language, information, communication, stigma and cultural relevance. 3.1.2.3.Some Other Models Developed in Australia Many other approaches to altering services so as to improve service access are now being applied across Australia, albeit most unevenly from state to state. Many of these innovative approaches are not service models so much as service catalysts. They include appointment of ethnic consultants in health regions in Victoria, the development of a resource kit to promote the acess to mental health services of people of NESB in Queensland, the non-English speaking background project being carried out in Western Australia (see Case Study 2). They seek to promote service access through an addition to the service, rather than through a logical overhaul of services according to stated principles, which is often not a practical option. The Multicultural Mental Health Access Project carried out in South Australia in 1996, however, developed a service model where each aspect of mental health service delivery was examined for its efficacy in promoting access. In this model, six elements of service development and delivery are seen as critical: • management commitment to NESB access; • appropriate policy development eg re time needed for effective clinical work with NESB people; re promoting information in languages other than English; re employing bilingual workers; • identification of key mental health worker responsible for NESB liaison; • cross cultural ongoing training for mental health workers; • culturally relevant service delivery eg incorporation of cultural understanding into clinical encounters; information provision in NESB languages in a variety of media; • participation in service development by members of NESB communities (Department of Health and Family Services 1996). A project carried out in Melbourne’s outer east in 1997 for the Eastern Regions Mental Health Association set out specifically to improve the access of NESB people in the

area to mental health services (Eastern Regions Mental Health Association 1997). Since Greek and Vietnamese communities are highly represented in the area, the project identified the needs of these communities, and the barriers to service they experience. However, the report describes a model for addressing the issues of access identified in the project more broadly. This model is referred to as “a replicable model of practice”. Its features are: • an initial understanding of the service area’s population; • an ethnic access audit to ensure the organisation’s structure is adequate to population needs; • an initial identification of community need and service delivery principles through concentration on several predominant ethnic groups; • addressing the information needs of the NESB population through “targeted communication”; • engagement and support of ethnic workers; • local and broader network development; • establishment of mechanisms to evaluate effectiveness. 3.1.3.

Common Features of Models of Access

All of these models have been developed in the course of practical attempts to identify and remove barriers to mental health service access for people of NESB. Their differences in emphasis reflect the specific contexts of their development, and none of their principles are mutually exclusive. They bear a consistent similarity in their criteria for improvement in service access. The essential identified features of good practice are: • assumption of responsibility by management for improvement in access • service development based on identified needs of local NESB population • provision of information about mental illness and about local mental health services in local community languages and using media which will reach NESB people • provision of resources to staff to overcome any language barriers • modes of service provision which meet client needs. eg outreach, home visits, same sex clinicians • management-supported service policies setting standards for service provision to NESB people • staff knowledge of local population and their cultural needs • training of staff in cultural issues • liaison with local NESB community groups • regular data collection of NESB-related information about service clients • culturally sensitive and appropriate program design • participation by NESB consumers and community groups in service development The discussion so far indicates that significant barriers to mental health service access still exist for people of NESB in Australia. It also shows that any way of addressing this on an Australia-wide basis has to take account of very different service structures at local, regional and state levels. What has been lacking until recently is an authoritative statement of the essential basis for good practice, which applies equally to all kinds of service, at different stages of development, and which will be acceptable to all services.

3.2. Overcoming the Barriers in Practice 3.2.1. Language and Communication: Access to Interpreters and Translation The most direct way to overcoming the language barrier is through the use of accredited interpreters. The Translating and Interpreting Service (TIS) is an Australia-wide general interpreter service conducted by the Commonwealth Department of Immigration and Multicultural Affairs. Available on a 24 hours a day seven days a week basis, it provides services in three major areas: telephone interpreting, on-site interpreting, and, translation TIS provides these services both to people of NESB and to government and community services who can purchase them to enhance their service delivery to people of NESB. These services (for example, community mental health centres) can then be reimbursed by their funding department, or they may come within exemptions specified by TIS, for example, medical practitioners, community organisations, non-profit organisations. Different arrangements exist from State to State, depending upon the arrangements through which health services are delivered (Department of Immigration and Ethnic Affairs 1996). In Victoria, health services are purchased by the Department of Human Services from health provider organisations on the basis of annually negotiated Agreements known as Funding and Service Agreements (FASAs). These Agreements specify how interpreters are to be made available and how they are to be funded, up to an agreed budget level. In the area of mental health service provision, budgets are calculated on the basis of a population formula weighted for NESB numbers at the rate of 1.6% of English speaking people in the service area. Area mental health services were also eligible in 1997 for a one-off payment based on achievement of targets, including that of responsiveness to people of NESB in their area. In 1995/96 Victoria allocated a total of $750,000 to mental health agencies in a state-wide budget for language services (Department of Human Services 1997b). Actual interpreter services in Victoria include: • the Central Health Interpreter Service (CHIS) a specialist health interpreter service funded by DHS; • the Victorian Interpreting Translating Service (VITS) - a state owned service which contracts with interpreting staff on a contract basis. DHS agencies are provided by DHS with a line of credit to VITS services. Under the relatively new arrangement of area-based Health Networks, these Networks now purchase their own interpreter services. In the case of mental health services, specific Area Mental Health Services receive in their overall funding the 1.6% weighting referred to above, and purchase interpreting services as needed; • The Translating and Interpreting Service. This is outlined above; • Private Professional Language Services. Mainly used as a back-up service; • Australian Association of Hospital Interpreters and Translators (AAHIT), a professional association working principally with eight major public health service providers in Melbourne.

Other States have different arrangements, based on explicit policies. In NSW a standard procedure for the engagement of interpreters is mandatory in all health agencies. Interpreters are provided through a network of area-based health interpreter services. Funding is calculated on the basis of the weighted cost of an occasion of service (centrally determined) and on an 85%/15% urban/rural split. Allocation is made to individual regions proportionately as indicated by the 1991 Census and modified by the addition of subsequent migration figures. When each region receives the funding, decisions as to purchase of interpreter services are made locally. In States where populations are much smaller than in Victoria and NSW, ie South Australia, Western Australia and Queensland, interpreter services are accessed chiefly through TIS. The availability of accredited interpreters is not a universal panacea for the problems of access to effective mental health services. Minas observes that the use of interpreter services works best when the same interpreter attends the patient throughout an entire episode of illness (Minas et al 1994). The use of interpreters in the services observed during the Case Studies appeared to be of most benefit where the mental health worker showed sensitivity to the client’s cultural needs. There are, however, circumstances where the nationality and language of the clinician seems not to be an issue for the client. In one instance, the presence of a skilled interpreter and the care taken by a mental health worker seemed to bridge the gap between the worker who was from a Mediterranean culture and clients from a diversity of cultures. *A mobile support team worker visited a Vietnamese family being reassured by the worker about their son’s recent admission to an inpatient Unit, and a Serbian woman being asked to share her feelings and to discuss her sleep problems. In each instance, the worker took great pains to identify matters of concern to the client. The interpreter worked very effectively with the worker. The visit was not concluded before the client expressed satisfaction and understanding - and, indeed, gratitude - to this young professional person who took such pains with each of his clients. *Staff of the CATT team at Mid-West Area Mental Health Centre always try to engage the services of the same interpreter throughout the episode of crisis, since this continuity reassures the client and the family, and makes the task of the CATT members easier. In another analysis of the interpreter service Australia-wide, Minas noted a number of problems related to the use of even accredited interpreters in the mental health setting (Minas et al 1996). In this situation, the interpreter is often seen as an unfortunate necessity, and takes on a role which both clinician and client distrust. Participating in a conference examining issues in the delivery of mental health services to Vietnamese people, Professor Minas summed up the difficulty for the interpreter. “What we expect of our interpreters is that they translate material which is as difficult to translate as poetry” (Vietnamese Community in Australia, South Australian Chapter 1993). Consultation for this project showed that a number of training programs for health professionals to work more efficiently with interpreters have been developed and are being enthusiastically attended by mental health service staff (eg the Rockingham Kwinana Area Mental Health Service). However, many people of NESB are unhappy

about confidentiality and privacy issues with interpreters, and prefer to attend a service, any service, where they can speak directly with the clinician in their own language. *A university-educated woman of Croatian background expressed a strong preference for attending a local Croatian-speaking GP rather than attending the Community Mental Health Centre. *Ethnic workers confirmed that a dislike of interpreter use and accompanying fears of breaches of confidentiality deterred most people contacted by them from attending a mental health centre. *An education worker has found that older people who have lost what English they may have acquired are comfortable only with same-language clinicians. 3.2.2. Assisting Cultural Sensitivity: Clinical Experiences and Solutions The general issue of effective access to mental health services has been considered, researched and debated. Lin lists a number of separate issues related to successful assessment and diagnosis with people of NESB (Lin 1990):

•

Adequate assessment involves the establishment of rapport with the client through demonstrating an understanding of the client’s experience and expectations.

•

Accurate diagnosis will depend upon the ability to distinguish in each case between normal grieving and clinical depression, and careful differentiation between the effects of the stresses of resettlement and the underlying condition.

•

Post-traumatic stress disorder is high among refugees, and may manifest itself a considerable time after the traumatising events, and may be misconstrued by a clinician (1990).

Both Rosado and Chiu in the United States have outlined cases where an accurate reading of the culture informing the client’s responses to mental illness was critical to accurate diagnosis and therefore effective treatment (Rosado 1980, Chui 1994). Rogler and his colleagues examined the meaning of culturally sensitive services in the context of an Hispanic population and outline a three step approach. • Firstly, the clinician must assess how appropriate western modalities of treatment will be for the client , by looking at the client’s likely understanding and acceptance of what the clinician has to offer, and by understanding the client’s community’s common response to mental illness. • Secondly, the clinician must then decide whether a directly western medical approach will be appropriate, or whether this will need modifying. • Thirdly, if the client is not sufficiently acculturated to western medical treatment, then treatment must be adapted to the client’s culture (Rogler et al 1987).

The principal way in which such a culturally sensitive method of clinical practice can be promoted is through education and training of staff. Summarising a number of studies of Puerto Rican mental health clients, Rosado et al advised that their under-utilisation of services should be addressed through needs assessments of each community, and education of mental health workers in the importance of family, folk healers and cultural values for Hispanic clients. Inclusion of this knowledge into service delivery practices through staff education and policy development is the next step. Other important means included: • education of leaders in the Puerto Rican community for participation on clinic boards, • locating clinics within the community, • employing more bilingual workers, • advertising services bilingually, • modifying initial sessions to make them more personal and informal, as well as • including Hispanic clients and a study of their culture in graduate training courses (Rosado 1980). Another study of Hispanic Americans emphasised that merely putting money into services was not sufficient unless these culturally relevant methods of service delivery were incorporated (Swanson et al 1993). Considering the needs of elderly people of NESB, Fellin and Powell emphasised the necessity for an outreach approach in order to ensure access (Fellin & Powell 1988). Summarising the particular needs of Vietnamese and Filipino clients, Flaskerud and Soldevilla observed that assistance was sought only in cases of extreme illness. They found that this could be improved through staff knowledge of and sensitivity to the cultural beliefs of these clients, with consequent modification of treatment modes, knowledge of their language, communication with their families and the use of outreach services (Flaskerud & Soldevilla 1986). This fits with Stolk’s findings regarding the placement of a Vietnamese Case Manager in the Western region of Melbourne (Stolk 1996). *A community ethnic worker observed that younger mental health workers are much more likely to respond to the challenge to extend their cultural understanding. She finds that many older workers are less self-critical of their own work, more rigid in their approach and have had less exposure to cultures other than their own. If this is broadly the case, it may be explicable in wider terms than their attitude to other cultures. University education in nursing is a very recent development in this country, and it is less than a decade since psychiatric nurses were trained “on the job” in large psychiatric hospitals conducted on lines very different from the present community based approach. Such workers have experienced many culture shocks over recent times, and the need for them to adapt their skills to the needs of NESB people is one to which good managers should respond with specific training. *The Director of an ethnic health centre noted that the onus is clearly on the worker to recognise the needs of clients, for whatever reason,. She maintains that a mental shift is needed for many workers towards a much more service-oriented approach. An ethos of “we are here to help you” would put the service worker in the best position to use the undoubted power he or she has. She firmly believes that Australian mental

health services need a profound change in service provision orientation and practice. So she would not want to focus so much on the needs of NESB people as to maintain that best practice takes account of all individual needs of the client and is mandatory. In this view, cultural knowledge and understanding becomes essential in the context of best practice. This is being recognised by mental health workers. When asked how their difficulties in providing good services to people of NESB could be best addressed, staff at the North Eastern Alliance for the Mentally Ill in inner suburban Melbourne stipulated: • cultural, religious and political background knowledge • a second language • better translated material • amongst other things (Velanovski 1996 , see P28 above). In a study of psychiatrically ill women in inner northern Melbourne, cultural understanding of clients by mental health service providers was seen as critical to successful service provision. Where this was missing, behaviour could be misconstrued, inappropriate advice given, insufficient time allowed for a consultation (North East Women’s Health Service 1994). *A young woman of Greek background active in the mental health consumer movement takes the more pragmatic view that where specified service supports are properly in place and made available to mental health workers, most cultural barriers can be addressed. These include: • the appointment of bilingual case managers in the major local community languages • buying in such case management skills from outside of the service area if necessary • training all staff in the use of interpreters • training all interpreters used in mental health services in relevant issues such as medical terminology and the necessity of interpreting word for word • effective service liaison with community groups, local GPs. 3.2.3. The Use of Bilingual Workers The use of bilingual workers in mental health clinics has been common in the United States, and is being introduced in Australia. In considering the general issue of the development, staffing and structuring of psychiatric clinics so that NESB people have the access they need, Kinzie noted in the US service context that the very qualities which untrained, non-professional bilingual workers offer which may enhance access can also work against it. They may share the prejudices and misunderstandings of clients or psychiatrists. They may be so unskilled as to be of minimal help, and may threaten the client’s belief in the service’s confidentiality standards. Kinzie recommends that these workers have good English skills, be skilled and sensitive interpreters, be sensitive to and pick up on any cultural misunderstandings on either side, have case management and some counselling skills and have the personal qualities of warmth, empathy, integrity and openness (Kinzie 1991).

Elsewhere in this review of mental health services for refugees in the USA, Egli looks at the role and limitations of bilingual workers in more detail. He examines their role in terms of the functions of translation, interpretation, cultural brokerage, outreach and community education, and mental health counsellor and co-therapist. There are difficulties in the execution of this last role where work with refugees is concerned, since they are likely to be particularly clinically needy, and adequate training and supervision is difficult to ensure (Egli, 1991). Egli sees the answers to these problems, as well as to the high rate of burnout in these workers, as lying in adequate and continuous funding, education and the political will to ensure appropriate service provision (Egli 1991, Adkins 1990). The problems associated with the use of bilingual workers which US writers have identified are not directly applicable to Australia. In the US, bilingual workers appear to be relatively unskilled workers whose main qualification is that they speak community languages and relate to people well. In Australia, bilingual workers encountered in the course of this project, and planned for in different areas, are health professionals who are also bilingual or multilingual. In this context, problems of burnout and skill deficits are unlikely to be relevant, since clinical tasks are being undertaken by highly trained professionals who are also culturally aware. In Victoria, the employment and utilisation of bilingual workers is being tackled strategically. The analysis of Minas, Ziguras at al in 1995 showed that less than 20% of Victorian mental health workers have a second language, and that where bilingual workers were employed, their language skills are inadequately used (Minas et al 1995). In 1996, as part of a strategy for developing more appropriate mental health services to people of NESB in Melbourne’s western suburbs, Stolk analysed actual service use by these people. Her study showed a marked under-utilisation (Stolk 1996). The Working Party developing this strategy have now, as part of their broader brief to make recommendations to improve mental health services, formally proposed a Bilingual Psychiatric Case Management Program. This Program has been developed for implementation as part of the Victorian Department of Human Services’ overall policy for better access for all Victorians to mental health services in the state (Ziguras 1997). The model proposed builds on identified bilingual strengths in mental health service personnel. All clinicians who are fluently bilingual are to be formally recognised as bilingual case managers, and given the flexibility to work across services and regions. Their role will cover primary clinical case management as well as a secondary consultative function in providing advice on cultural issues to other clinicians in their case management roles. The aim cannot be total matching of NESB clients with a case manager who speaks their preferred language. However, this scheme aims to use available bilingual resources to the broadest advantage. In specific cases, the emphasis of the bilingual case manager’s role will depend on the circumstances of their home base. This is rather different from what was observed in one of the Case Studies undertaken in this project. In this instance, one half of the bilingual case manager’s case load comprises general clients, and one half is language specific. They are also generally

available for local consultation, and play a role in bridge-building with other bilingual workers and regional Ethnic Consultants. One obvious danger is that far too many, and too important, roles are vested in the one worker, who must then respond to the most urgent demands. In this instance, the bilingual worker will be reactive rather than exercising initiative in role building and specialised service provision. The proposal does address these dangers. Bilingual workers have been participating in a pilot scheme in this area for two years of a proposed five year term, and lessons have been learnt from this experience. The proposal is detailed, and allows for evaluation. Other states tackle the need for bilingual workers differently. In Queensland, the Transcultural Mental Health Centre has a Chinese bilingual mental health worker, and also provides a secondary clinical support service. This service provides information, advice, resources and case discussions to mental health workers throughout Queensland. It will source professionals who match a client’s cultural and language needs and who will assist mental health workers with assessments and diagnoses. They will also assist in the development or review of individual care plans. These services can be provided via telemedicine where appropriate, a boon in such a large area as Queensland. Within the Brisbane metropolitan area, the government-funded Ethnic Mental Health Program provides cultural liaison support to mental health workers whose clients are Vietnamese, Greek, Chinese, Spanish-speaking, or Italian. In South Australia, the Migrant Health Service employs four bi-cultural health liaison workers to: • facilitate access to health services; • identify client and community needs; • pick up on issues of mis-communication and poor compliance; • act as cultural consultants; and • provide support to clients. In the context of the establishment of a system of area mental health services in South Australia, there appears to be a tension between the geographically self-sufficient mental health services recently mandated by government, and the use of bilingual or multilingual staff across areas where the need arises. The Migrant Health Service does not fit into the area-based model, and yet it does not have the resources to spread its human and financial capital across the areas without negating its specialist effectiveness. Queensland has approached this problem of making limited resources maximally available by working outside of the area based model. Victoria is aiming at regional self-sufficiency. The South Australian service focuses on the provision of specialist services, but in an environment which seems to be indifferent if not outright hostile to the need to employ people with specialist NESB skills for broad-based benefit. In Western Australia the lack of an impetus to regionalise services together with internal organisational change within the specialist migrant mental health service has led to an environment where individual skills appear to be used on a much more “ad hoc” basis. However, the very lack of formal structures supporting the provision of bilingual services

can make individual bilingual workers vulnerable to employment in much more generic tasks. *A bilingual mental health worker of considerable experience employed within a general hospital finds that she is continually pressured by the organisation to work in “mainstream” areas. She is rostered on for general emergency work, her position description is under review, and she fights a rear guard action to maintain a focus on clients of NESB. In NSW, the Transcultural Mental Health Centre provides telephone advice to mental health workers on assessment, care plans, options for referral and community support. The quality of this advice is underpinned by the expertise of a panel of sessional bilingual/ bicultural mental health professionals. This service is not an alternative to mainstream treatment and care for people of NESB. It rather provides for specialist input, free of charge, at the individual client level. At a broader level, the Centre aims to improve the access of NESB people to mental health services.

CHAPTER 4 DEVELOPING THE EVALUATION FRAMEWORK This project has built on the work of others in confirming that distinctive and ongoing barriers to service access continue to deter people of NESB from knowing about or seeking assistance in the event of serious mental illness. When services are sought, people still experience disadvantage because their prime language is not English, and because services tend to suit the “mainstream”. These barriers and deterrents have been confirmed by the experiences of NESB people and service providers recounted in the course of this project. Excellent work has already been done in modelling service responses to the identified barriers to service access. However, mental health direct care services in Australia take many forms, and must integrate into very different service systems in each state, and in some instances (eg Western Australia) are organised quite differently in different parts of a capital city. In this context, if a national approach to improving access is to succeed, a different approach must be taken. Most of the service models outlined in the previous chapter were devised in specific instances to address specific local problems. They serve the very useful purpose of articulating the problems and of devising solutions for specific areas or services. Or, as in the case of Minas’ work they constitute total systems analyses of the problem and proposed solutions at every level. The aim of this project has been to devise a way in which innovation and best practice in delivering mental health services to people of NESB can be identified, valued, legitimated, resourced, incorporated and evaluated at the primary care service delivery level, regardless of service structure or size. This chapter describes the framework developed for these purposes.

4.1. Scaffolding for the Evaluation Framework: National Standards for Mental Health Services A model for mental health service provision which incorporates all of the elements agreed to be essential to best practice is that of the National Mental Health Standards (Department of Health and Community Services 1996). These Standards were published in 1996 by the Commonwealth Government and endorsed by all State and Territory Governments. They have been developed as part of the National Mental Health Strategy. This Strategy originated in the National Mental Health Policy issued by all Australian Health Ministers in 1992 (Australian Health Ministers 1992, Australian Transcultural Mental Health Network 1996) and apply to all public mental health services in Australia. They are the national benchmark for best practice in mental health service delivery. As such, they comprise a critical reference point in the development in this project of criteria for excellence in mental health service delivery to people of NESB and an evaluation framework for services to apply to their activities in the light of these criteria. These Standards, endorsed by the Australian Health Ministers Advisory Council, were released in January 1997 for use by all Australian public Mental Health Services

(Department of Health and Community Services 1996). The National Mental Health Policy, on which they are based, was intended to set a new and more cohesive direction. It set out the details of this direction under the headings of: • consumer rights • the relationship between mental health services and the general health sector • linking mental health services with other sectors • service mix • promotion and prevention • primary care services • carers and non-government organisations • mental health workforce • legislation • research and evaluation • standards • monitoring and accountability Under each of these headings, issues are discussed and objectives for all services set out. The Policy identifies special ‘at risk’ groups, including people from non-English speaking background and emphasises the need for services to address the needs of all Australians particularly these ‘at risk’ groups (Australian Health Ministers 1992). The progress of each State and Territory in terms of each aspect of the Policy is monitored by the Commonwealth, and an Annual Report setting out the details of each State and Territory’s conformity to the policy is published. The National Standards represent a further step along the path towards achieving uniformly higher standards in mental health service delivery across Australia, and explicitly refer to the National Mental Health Policy and the United Nations’ Principles on the Protection of People with Mental Illness as their chief reference points. The Standards are, furthermore, intended to assist mental health service development and mental health service quality improvement. They are used as the basis of the criteria for best practice with mental health clients of NESB which have been developed in the context of this project because: • they have been agreed by all states • they apply to all public Mental Health Services • they will be known to all service providers • they apply to services to all clients, including those of NESB • they set the standard for best practice in Australia • they can address the issues related to service access identified in the current project. The specific areas covered by the Standards are: 1 Rights 2 Safety 3 Consumer and Carer Participation 4 Promoting Community Acceptance 5 Privacy and Confidentiality 6 Prevention and Mental Health Promotion 7 Cultural Awareness 8 Integration:

8.1 Service Integration 8.2 Integration within the Health system 8.3 Integration with Other Sectors 9 Service Development 10 Documentation 11 Delivery of Care 11.1 Access 11.2 Entry 11.3 Assessment and Review 11.4 Treatment and Support 11.4A Community Living 11.4B Supported Accommodation 11.4C Medication and Other Medical Technologies 11.4D Therapies 11.4E Inpatient Care 11.5 Planning for Exit 11.6 Exit and Re-entry. Recurring themes in these Standards of particular relevance to people of NESB include: • the need for documentation - of consumer contacts, of policies, protocols and procedures • practice which is consumer-centred and which integrates other services both internally and externally • evaluation and review - both of individual service plans and of the whole service • the need for a two way information flow - to and from the consumer, carer and community • priority for service provision to be given to those most in need of services. The National Standards for Mental Health Services are designed to be all-encompassing, addressing the needs of all sectors of the population. It might be expected that they would specifically apply in a limited sense to the particular issues identified in this project relating to service access for people of NESB. In fact they prove to be a particularly useful as well as authoritative basis for evaluating mental health services’ accessibility to people of NESB. The identified themes or critical issues of - Language; Lack of appropriate information; Poor communication; Stigma, and Cultural differences between client and clinician are addressed both across all of the Standards, and within specific Standards, as analysis of the Case Studies undertaken in the project show.

4.2. The Evaluation Framework for Best Practice The Evaluation Framework constructed as a response to the access issues identified earlier comprises several elements. Firstly, criteria for best practice have been developed so that mental health services can understand and organise their self-evaluation in an orderly, appropriately focused and and comprehensive way.

Secondly, Worksheets have been devised so that it is very easy for services to identify achievements, to record them, to specify timelines and progress and to create a program of development and review. Together, these tools allow a service to identify the areas for development and achievement, to record them, and to plan for improvement. As the National Standards point out, the use of the A or Attained rating indicates the achievement of a specific criterion with the recognition of the need for ongoing monitoring and review. It would be unusual that the N/A category would be used. It would be expected that review of the worksheets would occur regularly, eg, every three months, so that staff can be kept informed and corrective action can be taken speedily where appropriate.

4.3. The Criteria The criteria in the Evaluation Framework build on the National Standards, and provide an interpretation of their application to mental health service delivery to people of NESB. The criteria have been developed for use in mental health primary service delivery centres, where mentally ill people of NESB form part of the targeted service population. They are therefore most applicable to situations of direct consumer contact, rather than to services where secondary or tertiary consultancy is a major focus. The content of the criteria relates directly to the access and service provision issues and themes identified in the course of the project. 1. Rights 1.1 People of NESB have the right to be informed of their rights and responsibilities as consumers of the MHS: 1.1.1 as soon as possible after entry to the service 1.1.2 verbally and in writing 1.1.3 with the assistance of accredited interpreters 1.1.4 and to be provided, in an understandable form, with information about mental illness, available services and treatment options. 2. Safety 2.1 MHS consumers of NESB receive support and/or treatment (where appropriate) which protects them from any abuse and exploitation. 2.1.1 This includes abuse and/or exploitation perpetrated by other consumers, service staff members, other health service staff, family members or members of their ethnic community. 2.2 Support should include access to a staff member of the client’s gender, if requested and if possible. 3. Consumer and Carer Participation 3.1 MHS involves representatives of consumers and carers of NESB in all activities

directed towards ensuring community input to the MHS’s policies, procedures and programs. 3.2 This involvement includes policy, procedure and program evaluation. 4. Promoting Community Acceptance 4.1 MHS promotes acceptance of NESB people with mental illness within their ethnic communities, and within the general community. 4.2 MHS works with leaders of specific ethnic communities to identify the most culturally appropriate ways to achieve destigmatisation. 4.3 MHS provides an ongoing integrated program of accurate information and appropriate education about mental illness, and services and treatments for mental illness, in ethnic community forums and on ethnic radio and television. 4.4 MHS contributes to education of mainstream health workers about ethnicity and mental illness. 4.5 MHS involves and supports consumers and carers of NESB in providing information and education to ethnic community groups and to mainstream health workers. 5. Privacy and Confidentiality 5.1 MHS communicates its policy about privacy and confidentiality to all consumers and carers of NESB, verbally and in writing, in the consumer’s and carer’s preferred language. 5.2 MHS protocols regarding reception practices, records, the location of clinical sessions and necessary telephone conversations about consumers are designed and communicated both to reassure consumers and carers of NESB, as well as to ensure absolute privacy and confidentiality. 5.3 The physical environment of MHS allows privacy for consumers and carers of NESB in all their dealings with MHS staff. 5.4 MHS is flexible about the location of service provision; eg home visits. 6. Prevention and Mental Health Promotion 6.1 MHS ensures that information relating to prevention and to early detection of mental illness is communicated to the different ethnic communities in the MHS catchment area in a variety of media and locations. 6.2 MHS works with individual consumers and carers to make plans in the event of a relapse. 6.3 MHS workers maintain active liaison with ethnic community leaders so that they make appropriate referral of people of NESB to MHS. 7. Cultural Awareness 7.1 MHS maintains, and makes available to staff, current information about the variety and extent of communities of people of NESB in the catchment area. 7.2 MHS staff are trained in the cultural mores relevant to people of NESB in the catchment area. 7.3 MHS liaises with representatives of these local communities of NESB people, and with other local services, to ensure the cultural sensitivity of all aspects of service delivery to consumers and carers of NESB.

8. Integration 8.1 MHS policies, procedures, protocols and programs specifically related to people of NESB are communicated to all staff in MHS. 8.2 All aspects of MHS programs are available as appropriate to consumers and carers of NESB. 8.3 Each consumer of NESB has a single MHS staff member responsible for all aspects of service integration, internal and external, relating to the consumer. 9. Service Development 9.1 MHS ensures that all staff are aware of their roles and responsibilities relating to consumers and carers of NESB. 9.2 MHS planning processes and documents specifically refer to the needs of NESB consumers, carers and communities, including the need for outreach work necessary to identify people of NESB who might benefit from MHS services. 9.3 MHS resources are allocated to ensure the achievement of service outcomes for all consumers of NESB at the same level as those for English-speaking consumers. 9.4 MHS data collection includes material relating to consumers and carers of NESB necessary for the delivery of effective and culturally sensitive services. 9.5 MHS evaluation methods make specific reference to service effectiveness for consumers of NESB. 10. Documentation 10.1 MHS documentation protocols and practices relating to people of NESB comply with National Standards. 10.2 The content and purpose of all documentation relating to consumers and carers of NESB is communicated, where clinically appropriate, to the consumer and carer verbally and in writing in their preferred language. 11. Delivery of Care 11.1 MHS care, treatment and support to consumers and carers of NESB incorporates the provision of choice in location, treatment mode and treating clinician. 11.2 Treatment appropriateness, effectiveness and acceptability to each individual MHS consumer of NESB is optimised, and prioritisation of the most clinically needy is ensured. 11.3 Assessment of people of NESB at the initial contact with MHS is responsive to their specific needs in terms of cultural sensitivity, timeliness, style and location. 11.3.1 This assessment involves appropriate coordination with other services. 11.3.2 This assessment is regularly reviewed according to National Standard 11.3. 11.4 Culturally appropriate individual care plans are drawn up and regularly reviewed with consumers and carers. 11.5 MHS consumers and carers of NESB are fully informed in their preferred language about treatment options, and their informed consent is obtained before treatment proceeds. 11.6 Consumers and carers of NESB are supported by MHS in choice of the setting for treatment. 11.7 Treatment of MHS consumers of NESB is monitored for adverse side effects. 11.8 Where MHS provides treatment to consumers of NESB in an inpatient setting, information, orientation and introductions are made available in the consumer’s and carer’s preferred language.

4.4. The Worksheets It is essential that the worksheets to assist and record evaluation, and which accompany these criteria are familiar to services, are easy to use, and can be adapted to any means of service data collection and any service structure. The purpose of the dual tool for service criteria and evaluation is to enable services to understand what aspects of service provision need to be monitored and improved, and to be able to know whether progress is being made, without the need for time-consuming research. It should reveal what has been done, how well it has been done and what remains to be done, all in the context of the service’s more general goals. It should be readily useable by nonspecialists in service evaluation. It should be simple, but not simplistic. The developed evaluation framework utilises and adapts the worksheets which form part of the evaluation tool accompanying the National Standards, on the basis that service providers will be building familiarity with these. No specialist expertise will be needed to use the worksheets, and the data obtained will be directly comparable with other data collected by the service via the National Standards worksheets. Accuracy of comparison will be enhanced if the same person fills in the worksheets at successive evaluation dates. If this is not possible, then the incumbent of the same position, eg the manager, should do so each time, using the same kind of data supplied by workers’ standard records. The rating codes are those used in the National Standards worksheets. Individual services may wish to cross reference the data on future service improvements either to their own attached documents, or to other service records which they keep for the purposes of ongoing service evaluation and quality improvement. This could be particularly useful where a criterion is partially met, or not met, so that proposed remedial action or service development can be recorded and subsequently evaluated.

1 Rights The rights of people affected by mental disorders and/or mental health problems are upheld by the MHS RATING* Tick the appropriate rating

1.1.1

Rights

1.1.2

Rights

1.1.3

Rights

1.1.4

AI UA NA

Who is the person responsible

(Identify what the MHS needs to do in order to attain the criterion at the next review and how progress will be fed back to those concerned)

(Identify the person(s) responsible for ensuring attainment of the criterion at the next review and reporting progress)

When will the next review of this criterion occur? (State a date by which improvement with the criterion could be expected and progress reported)

Rights

How could the MHS Improve?

* A - Attained;

AP - Attained Partially;

AI - Attainment Initiated;

UA - Unattained;

NA - Not Applicable.

2 Safety The activities and environment of the MHS are safe for consumers, carers, families, staff and the community. Criterion Name and Number Tick the appropriate rating

Safety

2.1

Safety

2.1.1

Safety

2.2

* A - Attained;

RATING* A

AP - Attained Partially;

How could the MHS Improve?

Who is the person responsible

When will the next review of this criterion occur?

(Identify what the MHS needs to do

(Identify the person(s) responsible

(State a date by which

in order to attain the criterion at the

for ensuring attainment of the

improvement with the criterion

next review and how progress will

criterion at the next review and

could be expected and progress

be fed back to those concerned)

reporting progress)

reported)

AI - Attainment Initiated;

UA - Unattained;

NA - Not Applicable.

3 Consumer and Carer Participation Consumers and carers are involved in the planning, implementation and evaluation of MHS programs. Criterion Name and Number Tick the appropriate rating

Participation

3.1

Participation

3.2

* A - Attained;

RATING* A

AP - Attained Partially;

How could the MHS Improve?

Who is the person responsible

When will the next review of this criterion occur?

(Identify what the MHS needs to

(Identify the person(s) responsible

(State a date by which

do in order to attain the criterion at

for ensuring attainment of the

improvement with the criterion

the next review and how progress

criterion at the next review and

could be expected and progress

will be fed back to those concerned)

reporting progress)

reported)

AI - Attainment Initiated;

UA - Unattained;

NA - Not Applicable.

4 Promoting Community Acceptance The MHS promotes community acceptance and the reduction of stigma for people affected by mental disorders and/ or mental health problems. Criterion Name and Number A

Tick the appropriate rating

RATING*

How could the MHS Improve?

Who is the person responsible

When will the next review of this criterion occur?

(Identify what the MHS needs to

(Identify the person(s) responsible

(State a date by which

do in order to attain the criterion

for ensuring attainment of the

improvement with the criterion

at the next review and how progress

criterion at the next review and

could be expected and progress

will be fed back to those concerned)

reporting progress)

reported)

AI UA NA

Community Acceptance 4.1

Community Acceptance 4.2

Community Acceptance 4.3

Community Acceptance 4.4

Community Acceptance 4.5

Community Acceptance 4.6

* A - Attained;

AP - Attained Partially;

AI - Attainment Initiated;

UA - Unattained;

NA - Not Applicable.

5 Privacy and Confidentiality The MHS ensures the privacy and confidentiality of consumers and carers. Criterion Name and Number

RATING* A

Tick the appropriate rating

AI UA NA

How could the MHS Improve?

Who is the person responsible

When will the next review of this criterion occur?

(Identify what the MHS needs to do

(Identify the person(s) responsible

(State a date by which improvement

in order to attain the criterion at the

for ensuring attainment of the

with the criterion could be expected

next review and how progress will

criterion at the next review and

and progress reported)

be fed back to those concerned)

reporting progress)

Privacy and Confidentiality 5.1

Privacy and Confidentiality 5.2

Privacy and Confidentiality 5.3

Privacy and Confidentiality 5.4

* A - Attained;

AP - Attained Partially;

AI - Attainment Initiated;

UA - Unattained;

NA - Not Applicable.

6 Prevention and Mental Health Promotion The MHS works with the defined community in prevention, early detection, early intervention and mental health promotion. Criterion Name and Number

RATING* A

Tick the appropriate rating

AI UA

How could the MHS Improve?

Who is the person responsible

When will the next review of this criterion occur?

(Identify what the MHS needs to

(Identify the person(s) responsible

(State a date by which

do in order to attain the criterion at

for ensuring attainment of the

improvement with the criterion

he next review and how progress

criterion at the next review and

could be expected and progress

will be fed back to those concerned)

reporting progress)

reported)

Prevention and Promotion 6.1

Prevention and Promotion 6.2

Prevention and Promotion 6.3

* A - Attained;

AP - Attained Partially;

AI - Attainment Initiated;

UA - Unattained;

NA - Not Applicable.

7 Cultural Awareness The MHS delivers non-discriminatory treatment and support which are sensitive to the social and cultural values of the consumer and the consumer’s family and community. Criterion Name and Number

Tick the appropriate rating

RATING*

How could the MHS Improve?

Who is the person responsible

When will the next review of this criterion occur?

AP AI UA NA

(Identify what the MHS needs to do

(Identify the person(s) responsible

(State a date by which

in order to attain the criterion at the

for ensuring attainment of the

improvement with the criterion

next review and how progress will

criterion at the next review and

could be expected and progress

be fed back to those concerned)

reporting progress)

reported)

Cultural Awareness 7.1

Cultural Awareness 7.2

Cultural Awareness 7.3

* A - Attained;

AP - Attained Partially;

AI - Attainment Initiated;

UA - Unattained;

NA - Not Applicable.

8 Integration The MHS is integrated and coordinated internally and with other services and sectors, which ensures continuity of care and integration with the community for the consumer. Criterion Name and Number

Tick the appropriate rating

Integration

8.1

Integration

8.2

Integration

8.3

* A - Attained;

RATING* A

UA NA

AP - Attained Partially;

How could the MHS Improve?

Who is the person responsible

When will the next review of this criterion occur?

(Identify what the MHS needs to do

(Identify the person(s) responsible

(State a date by which

in order to attain the criterion at the

for ensuring attainment of the

improvement with the criterion

next review and how progress will

criterion at the next review and

could be expected and progress

be fed back to those concerned)

reporting progress)

reported)

AI - Attainment Initiated;

UA - Unattained;

NA - Not Applicable.

9 Service Development The MHS is managed effectively and efficiently to facilitate the delivery of coordinated and integrated services. Criterion Name and Number

Tick the appropriate rating

A AP

RATING*

How could the MHS Improve?

Who is the person responsible

AI UA NA

(Identify what the MHS needs to do

(Identify the person(s) responsible

(State a date by which

in order to attain the criterion at the

for ensuring attainment of the

improvement with the criterion

next review and how progress will

criterion at the next review and

could be expected and progress

be fed back to those concerned)

reporting progress)

reported)

When will the next review of this criterion occur?

Service Development 9.1

Service Development 9.2

Service Development 9.3

Service Development 9.4

Service Development 9.5

* A - Attained;

AP - Attained Partially;

AI - Attainment Initiated;

UA - Unattained;

NA - Not Applicable.

10 Documentation Clinical activities and service development activities are documented to assist in the delivery of care and in the management of services. Criterion Name and Number

Tick the appropriate rating

Documentation

10.1

Documentation

10.2

RATING*

How could the MHS Improve?

Who is the person responsible

When will the next review of this criterion occur?

AP AI UA NA

(Identify what the MHS needs to do

(Identify the person(s) responsible

(State a date by which

in order to attain the criterion at the

for ensuring attainment of the

improvement with the criterion

next review and how progress will

criterion at the next review and

could be expected and progress

be fed back to those concerned)

reporting progress)

reported)

57 * A - Attained;

AP - Attained Partially;

AI - Attainment Initiated;

UA - Unattained;

NA - Not Applicable.

11 (a) Delivery of Care The care, treatment and support delivered by the MHS is guided by principles upholding choice, and comprehensive, individual, continuous and coordinated care in the least restrictive way, respecting the consumer’s social, cultural and developmental context. Criterion Name and Number

Tick the appropriate rating

RATING* A AP AI UA NA

How could the MHS Improve?

Who is the person responsible

When will the next review of this criterion occur?

(Identify what the MHS needs to do

(Identify the person(s) responsible

(State a date by which

in order to attain the criterion at the

for ensuring attainment of the

improvement with the criterion

next review and how progress will

criterion at the next review and

could be expected and progress

be fed back to those concerned)

reporting progress)

reported)

Care Delivery 11.1

Care Delivery 11.2

Care Delivery 11.3

Care Delivery 11.3.1

Care Delivery 11.3.2

Care Delivery 11.4

Care Delivery 11.5

Care Delivery 11.6

* A - Attained;

AP - Attained Partially;

AI - Attainment Initiated;

UA - Unattained;

NA - Not Applicable.

11 (b) Delivery of Care The care, treatment and support delivered by the MHS is guided by principles upholding choice, and comprehensive, individual, continuous and coordinated care in the least restrictive way, respecting the consumer’s social, cultural and developmental context. Criterion Name and Number

Tick the appropriate rating

RATING* A

How could the MHS Improve?

Who is the person responsible

When will the next review of this criterion occur?

(Identify what the MHS needs to do

(Identify the person(s) responsible

(State a date by which

in order to attain the criterion at the

for ensuring attainment of the

improvement with the

next review and how progress will

criterion at the next review and

criterion could be expected

be fed back to those concerned)

reporting progress)

and progress reported)

Care Delivery 11.7

Care Delivery 11.8

Care Delivery 11.9

Care Delivery 11.10

Care Delivery 11.11

* A - Attained;

AP - Attained Partially;

AI - Attainment Initiated;

UA - Unattained;

NA - Not Applicable.

CHAPTER 5 THREE CASE STUDIES OF CURRENT PRACTICE 5.1 Introduction The evaluation framework for use by mental health services was developed through the identification of relevant issues and themes, and utilising and adapting the National Standards as a vehicle to address these issues. To test this evaluation framework in terms of its usefulness in addressing the issues and its ease of use by services, Case Studies in three Community Mental Health Services were conducted, in order to: • identify aspects of good practice in ensuring effective access to services • identify the important contextual and structural supports to this good practice in each case • identify the different opportunities for innovative practice which arise for different personnel within the Service • identify cooperative practices with other services and organisations which assist NESB access to the Service • trial the draft criteria with each Service, and to receive the response of the Service to the appropriateness and ease of application of the draft criteria. Three Community Mental Health Services, one each in Victoria, Western Australia and Queensland, were identified and targetted on the basis of advice from senior mental health professionals with expertise in NESB issues in each of these States (see Appendix 13). The Director of each Service was telephoned and invited to participate in the proposed Case Study. They were informed about its content and purpose, and its place in the project as a whole. The Director was also informed of the approach to understanding the Service which the Project Officer wished to pursue whilst there. It was emphasised that there should be no disruption to the work of the Service by the operation of the Case Study, and no variation in everyday practice, and that informed consent would be sought from clients and/or carers, as necessary. When provisional verbal agreement to each Case Study was given, a letter of confirmation was sent to the Service Director. The Director was requested to distribute copies of this material to all Unit Managers, and to obtain any permission needed, eg from a Board of Management, for the Case Study to proceed. When this confirmation was provided by the Director, arrangements were finalised for the Project Officer to attend the Service for two or four days, following an itinerary organised by the Service on the basis of the Study requirements outlined by the Project Officer. After each Case Study was completed, a report of the Study was written, based on materials provided, notes taken during the Study and observations made by the Project Officer. This information was analysed in order to inform the Report. Follow-up occurred in order to assist responses by the Service Directors on the draft criteria and the draft evaluation framework.

5.2. Case Study 1: Mid West Area Mental Health Services (Melbourne, Victoria) 5.2.1. Service Description Mid West Area Mental Health Service (Mid West AMHS) is part of the Mental Health Program of the North West Health Network (NWHN). This Service provides assessment and treatment services to people aged 16-64 who live in the municipalities of Melton, Brimbank and part of Hume (Bulla, Sunbury) and who have a serious mental illness and/or associated psychiatric disability. This includes people with severe mood, eating, anxiety and personality disorders, and those with psychosis. Individuals access these component services through a duty/triage system (located at the Continuing Care Team during business hours and at the hospital after hours), and they are then allocated a case manager who co-ordinates their care. The specific components are as follows: •

The Continuing Care Team (CCT): The CCT provides intake and assessment services, and is responsible for the duty /triage system during business hours. It also provides case management, treatment, support and consultancy services. Access to this service is generally by self- or GP-referral. This team is the clinic based group of mental health workers who provide clinical support to mentally ill people who are well enough to attend the clinic, and who attend regularly, on an appointment basis, but not often.

•

The Crisis Assessment and Treatment Team (CATT) Service: The CATT service provides a 24-hour mobile assessment and treatment service for people experiencing psychiatric crisis.

•

The Mobile Support and Treatment (MST) Service: The MST service provides ongoing treatment and support, as well as social and vocational rehabilitation, to clients living in the community. They work intensively on a case management basis with a small number of clients who are considered to be at risk of readmission due to recurrent serious mental illness and continuing disability. The service operates on a 7-day, extended hours basis.

•

Community Care Units (CCU): This accommodation service aims to enhance the functioning, self-esteem and independence of clients with serious mental illness and associated psychiatric disability, by equipping them with living skills necessary for functioning in the community. Access to the CCU occurs via the MST service.

•

Adult Acute Psychiatric Unit: This unit is located at Sunshine Hospital and has 5 “high dependency” beds and 20 “low dependency” beds. It provides short term, voluntary and involuntary assessment and treatment services during an acute phase of a client’s serious mental illness. As in all other Units, interpreters are used whenever needed.

5.2.2. Demographic characteristics of the service’s catchment area Approximately 200,000 people live within the catchment area of Mid West AMHS. Approximately 38% of the 200,000 are from a non-English speaking background, the majority living in the City of Brimbank. The largest birthplace groupings are people from the former Yugoslavia, Malta, Vietnam, Italy and Greece. In terms of language, 55.4% of Brimbank’s residents speak a language other than English. At the top level, the North West Health Network Mental Health Program has policies and procedures relating to culturally sensitive practice (Western Health Care Network Mental Health Program Policy and Procedures Manual, February 1997. Note: This Network is now known as the North West Health Network (NWHN), and is referred to as such here). These policies and procedures address the following issues of access for people of NESB: •

Designated responsibility within services: Responsibility for the co-ordination of ethnic health activities is allocated to a senior staff member, who will report regularly to the relevant Area Manager and Local Executive.

•

Access: Mental health services endeavour to reduce barriers to service use, based on language, culture, structure, lack of information and/or stigma.

•

Language services: Only appropriately accredited interpreters or bilingual clinical staff provide these, except in an emergency. Written information is to be available in translated form in major community languages.

•

Assessment and treatment: Assessment, treatment and case management is to be undertaken with an awareness of the cultural framework of both the consumer and the clinician.

•

Staff training and development: Services are to encourage and make provision for clinicians to undertake training in cultural issues in mental health. supervision.

•

Information provision: Services and staff are to be well resourced in information on the distribution of ethnic communities in their catchment area and on culturally sensitive practice.

•

Staff recruitment: Services are to endeavour to reflect in their staff profile the ethnic composition of their catchment area.

Other policy documents flow from this, providing a framework for service delivery at each of the levels of the organisational structure. Specifically, there is an Area Policy on Culturally Sensitive Practice (Mid West AMHS Policy and Procedure Manual, n.d.), and a Program Policy on Culturally Sensitive Practice (Program Policy and Procedure Manuals, n.d.). Both of these policies provide guidance for Area Managers and Program Managers with regard to achieving the outcomes outlined in the six areas described above (Appendix No 2).

5.2.3. Mid West and the Evaluation Framework The Mid West Area Mental Health Centre provides good services to people of NESB. Senior management sets the tone, provides the resources, and encourages innovation in program and project development. Program managers are enthusiastic, dedicated, supportive of their staff, and aware of the special needs of people of NESB. They can call on bilingual workers for help in cultural understanding, and have an open budget for the use of interpreters where needed. Individual managers showed compassionate understanding of small issues which can make a large difference, for example the carefully thought out plan by which the manager of the CCU ensured that every resident attended their family’s Christmas dinner at just the time the family wanted them there. Every Program shows a high level of morale and confidence which flowed over into individual worker attitude and performance. How then could the Evaluation Framework assist such an organisation, where evaluation and accountability are expected, and where there exists a high level of awareness of the need to ensure access to mental health services for people of NESB? The application of the criteria to the information derived from the Case Study provides an illustration of how the Framework can be useful to such an organisation.

Interpreter use occurs relatively frequently. Table 1 shows the interpreter use by all programs within Mid West AMHS (excluding the Adult Acute Psychiatric Unit) over the 6-month period 1 April to 30 September 1997. In total, during this period, there were 353 occasions of interpreter use over this period, with the majority occurring in the CCU. Interpreter use was most common for Vietnamese speakers. In terms of the appointment of bilingual staff, it is also clear that practice is following policy. Table 2 provides a breakdown of the bilingual staff employed by the different programs within Mid West AMHS. In total, 20 bilingual workers are currently employed out of a total staff of 92.

Table 1: Occasions of interpreter use (Victorian Interpreting and Translating Services) by Mid West Area Mental Health Service, 1 April - 30 September 1997

Vietnamese Macedonian Croatian Turkish Greek Serbian Cantonese Polish Italian Romanian Slovene Bosnian Maltese Mandarin Hakka Spanish Thai Tongan Portugese TOTAL

CCT 74 41 25 19 18 16 10 9 8 4 4 3 3 3 2 1 1 1 242

CAT Service 18 1

MST Service 36 3 5 1 2 9

CCU

1 22

Ongoing efforts are undertaken to ensure that service and educational information is available in community languages. For example, multilingual posters/brochures are displayed in a range of languages. These describe services and support provided by VITS, the Schizophrenia Fellowship and ADEC. In addition to utilising existing promotional material, Mid West AMHS has been proactive in developing new material, such as a multilingual “Mental Illness Awareness” educational package for clients and carers, and multilingual Area and Program information kits. It has also lobbied Human Services, Victoria (via the VTPU) to have the Mental Health Act translated (Mid West Area Psychiatric Services: Demographics, n.d.)

Table 2: Bilingual Staff Employed by Mid West AMHS, by Language Group, 1 April to 30 September 1997 CCT Turkish Greek Chinese/Malay French Croatian Serbian Maltese Macedonian Italian Cantonese/ Man-darin 1 Cantonese Bakaja/Malay TOTAL

CAT Service

MST Service

CCU

Adult Acute Psychiatric Unit

1 2 1 1 1

1 1

1 1 7

1 2 1

Melita is a 43 year old Bosnian woman who arrived in Australia after spending five years in war-torn Sarajevo. She is experiencing depression and anxiety, and feels isolated. She has been referred to Mid West AMHS by a torture and trauma worker from Foundation House, who feels that her medication is being mismanaged. Present with Melita at this session are the torture and trauma worker, a Bosnian interpreter from VITS, and a psychiatric registrar and a CCT worker from Mid West AMHS. Melita is introduced by the torture and trauma worker, via the interpreter, to everyone in the room, and the roles of each person are explained. The session continues with the interpreter professionally overcoming the language barrier between Melita and the service providers. The psychiatric registrar begins by inviting Melita to describe the issues she is facing, drawing her out on positive, as well as negative, aspects of her current situation. Melita explains that she is very happy with her torture and trauma worker. However, she feels that her GP is too far away and is not monitoring her medication, just giving her repeat prescriptions. The team work co-operatively to assist Melita to find a solution, always including her in discussion and decisionmaking. The psychiatric registrar recommends strongly that she continue seeing her torture and trauma worker, and this is well-received. When Melita says she does not want to attend the AMHS, the CCT worker suggests referral to a good local GP, asking Melita about preferences for ethnicity and gender. Melita says that she would be keen to see someone from Bosnia or Croatia, but not Serbia. She is referred to a local Croatian woman GP, who has worked closely with Mid West AMHS in the past. She is also provided with the phone number of the CCT, and invited to ring it if she feels she needs to. She is clearly surprised and delighted with the outcome, and the level of understanding and empathy shown by all contributing to the discussion.

2. Safety 2.1 MHS consumers of NESB receive support and/or treatment (where appropriate) which protects them from any abuse or exploitation. 2.1.1 This includes abuse and/or exploitation perpetrated by other consumers, service staff members, other health service staff, family members or members of their ethnic community. 2.2 Support should include access to a staff member of the client’s gender, if requested and if possible. Network policy is that respect is shown for gender privacy and political considerations expressed by consumers when interpreters or bilingual staff are involved. Combined with the revision of clinical forms to include questions relating to language and cultural issues of clients and carers, this should ensure that any specific preferences are accommodated. This may vary from program to program. The CATT manager pointed out that while preferences for a male or female staff member is respected wherever possible, this cannot always be accommodated in an emergency. The needs and safety of the client are paramount. This was illustrated by a MST member in an instance where a young man’s family kept intervening in his treatment to his detriment. Finally, the MST resolved that they must insist that their treatment plan be carried out in spite of the client’s family’s resistance. 3. Consumer and Carer Participation 3.1 MHS involves representatives of consumers and carers of NESB in all activities directed towards ensuring community input to the MHS’s policies, procedures and programs. 3.2 This involvement includes policy, procedure and program evaluation. Network policy is that all services will consult with communities, consumers and carers to identify appropriate strategies for reducing barriers to access, and that all translated material will be piloted with relevant consumers before the information is printed. At the service level, this policy is being implemented in a carers’ project which is working with the NESB community to identify ways to make the service more responsive to their needs. While there does not appear to be a single mechanism for ensuring community input into policy, when issues specific to NESB are identified, their input is sought. A NESB Carers Project aims to develop a model of service response which is tailored towards the specific needs of non-English speaking carers. Recognising that nonEnglish speaking carers are not a heterogeneous group, the project team is working closely with local communities, carers and other service providers to develop strategies to optimise service responsiveness.

Cam and Hung are a middle-aged Vietnamese couple who moved to Australia one year ago, with their son Dan (24) and sons Trang (16) and Vung (14). Dan (24), has been admitted to hospital with psychotic symptoms. As arranged upon Dan’s admission, a worker from the MST Service is visiting Cam and Hung at home. The MST worker arrives with an interpreter from VITS. Through the interpreter, the worker explains that he is there to provide them with some information about their son’s condition and its treatment, and to answer any questions they may have. He begins by explaining what a psychotic episode is like for the sufferer, describing how, when Dan asked him to take him to hospital, he said that he felt he had animals in his body. Cam noted that he had made similar statements to her over the past, adding that she first began noticing his symptoms about two years ago. The worker continues, providing a simple and clear description of how Western medicine conceptualises schizophrenia, acknowledging that Cam and Hung may have a different view. Cam asks whether her son will ever recover. The MST worker explains that there is no cure, but that symptoms can be controlled quite effectively if they are picked up early and treated with the appropriate medication. He stresses the importance of ensuring that Dan is compliant with his medication when he returns home, noting that this means taking the right amount at the right time. He discusses with Cam and Hung the fact that Dan has indicated to him that he is scared about the consequences of taking the medication, and will need their support and reassurance. Cam feels confident that they can provide this support, noting that Dan is less fearful now than he used to be. Cam asks about the causes of schizophrenia. The MST worker says in simple terms that Western medicine recognises three contributory causes, genetic, environmental and biochemical. His explanation satisfies the parents, and the encounter ends with their expressions of confidence and gratitude . 4. Promoting Community Acceptance 4.1 MHS promotes acceptance of NESB people with mental illness within their ethnic communities, and within the general community. 4.2 MHS works with leaders of specific ethnic communities to identify the most culturally appropriate ways to achieve destigmatisation. 4.3 MHS provides an ongoing integrated program of accurate information and appropriate education about mental illness, and services and treatments for mental illness, in ethnic community forums and on ethnic radio and television. 4.4 MHS contributes to education of mainstream health workers about ethnicity and mental illness. 4.5 MHS involves and supports consumers and carers of NESB in providing information and education to ethnic community groups and to mainstream health workers.

At Network level, policy is to undertake community education projects through appropriate media, and to develop partnerships with bilingual GPs and other ethnic health services to assist NESB service access. At the service level, Mid West is represented on the Western Region Ethnic Issues Group, which meets regularly and works to improve and advocate for services for NESB people. The Carers’ Project aims at the greater acceptance of NESB people with a mental illness, both in their own communities and in the wider community. The service is also in the process of developing multilingual information packages for clients and carers, with a distribution policy within each program.

5. Privacy and Confidentiality 5.1 MHS communicates its policy about privacy and confidentiality to all consumers and carers of NESB, verbally and in writing, in the consumer’s and carer’s preferred language. 5.2 MHS protocols regarding reception practices, records, the location of clinical sessions and necessary telephone conversations about consumers are designed and communicated both to reassure consumers and carers of NESB, as well as to ensure absolute privacy and confidentiality. 5.3 The physical environment of MHS allows privacy for consumers and carers of NESB in all their dealings with MHS staff. 5.4 MHS is flexible about the location of service provision;eg home visits. Network policy is that respect is shown for privacy considerations when interpreters or bilingual staff are involved. This can be ensured to some extent by the engagement of professional interpreters only, and this is policy at Mid West. Clients are interviewed in clinicians’ offices, which are well away from the waiting area, and closed during consultations. The reception area is also closed off from the waiting area, so that telephone conversations cannot be overheard. There was no evidence that the Service’s policy about privacy and confidentiality is written and translated, although the current development of multilingual Area and Program information kits should address this. At the level of practice, each worker observed during the Case Study checked politely with the client before a consultation in order to establish that they did not object to the project officer’s presence. Home visits seemed to be standard practice, particularly for the MST, while the basis for the CCT is clinic-based meetings. Where clients or their families did not want to attend the clinic, workers were prepared to negotiate an alternative. When an eastern European family did not want the MST to visit their home to see their son, and they were not willing to come to the clinic, it was arranged that the son attend the clinic, and the family were to be updated about his progress by telephone. All files at the clinic were observed to be in locked cabinets, and the prevailing attitude and practice were to respect the privacy of each client. The CATT had developed separate protocols for working with the police and ambulance services, and met regularly with these services in order to discuss ways to minimise distress to clients in an emergency.

6. Prevention and Mental Health Promotion 6.1 MHS ensures that information relating to prevention and to early detection of mental illness is communicated to the different ethnic communities in the MHS catchment area in a variety of media and locations. 6.2 MHS works with individual consumers and carers to make plans in the event of a relapse. 6.3 MHS workers maintain active liaison with ethnic community leaders so that they make appropriate referral of people of NESB to MHS. At Network level, policy is that services work to inform ethnic communities about mental health issues and services. At Service level, this happens in a number of ways. Involvement in the Ethnic Issues Group in the area keeps the Service informed about education and information needs, and gives it the opportunity to supply these. However, there is a lack of ethno-specific organisations in the area, so that the Service cannot readily communicate with community representatives, relying instead on individual contact, and on working with agencies such as ADEC and the VTPU to devise education strategies. The Service’s initiatives for informing and educating people of NESB are essentially internal, and it is not involved in ethnic radio, newspapers or organisations. Neither does it have an outreach program, beyond the carers’ project, which aims, inter alia, to develop information and education packages which are specific to NESB carers’ needs. At the Program level, it was evident in Case Planning meetings, and in visits made with the MST that workers actively plan for relapses, by maintaining a high level of awareness of each client’s current state and of family structures and supports, and by good communication with families.

Health Consultant offers staff access to a broader view of local issues, as well as to advice across a range of cultural issues. Three bilingual case management positions are funded and occupied, providing specialist skills in Macedonian, Vietnamese and Italian cultural issues. The Carers’ Project aims to increase NESB people’s input into the Carers’ Group, and a joint project is being developed with ADEC to improve service provision through improved social support. *Some families of NESB residents in the CCU were keen to have their ill member home for Christmas dinner, but have difficulty negotiating a precise time length with them, and arranging their pick-up and return. Staff negotiated with each family separately, and arranged for every resident invited out on Christmas Day to be transported both ways at times to suit their families. *A carers group at the CCU received a big boost when parents of NESB were invited to attend a lunch with food from their culture. Similarly, a concert was a great success when NESB carers contributed with their culture’s music.

8. Integration 8.1 MHS policies, procedures, protocols and programs specifically related to people of NESB are communicated to all staff in the MHS. 8.2 All aspects of MHS programs are available as appropriate to consumers and carers of NESB. 8.3 Each consumer of NESB has a single MHS staff member responsible for all aspects of service integration, internal and external, relating to the consumer. At Mid-West, staff receive this kind of communication in several ways. Firstly, specific policies and protocols have been developed and printed, and were observed to be available and communicated. Secondly, staff development programs related to crosscultural sensitivity have highlighted the relevance and importance of these policies and protocols. Thirdly, management at every level find specific ways of communicating these, and underscoring their importance. For example, a clinician in the CATT was delegated responsibility for issues related to NESB people which arise in the context of the CATT; the Director has an open-ended budget approach to the use of interpreters where needed, and it was observed that all staff members were aware of this. Fourthly, the importance of NESB issues is reinforced structurally - in the appointment of bilingual workers, in the appointment of a worker responsible for culturally sensitive issues, in the allocation of resources to projects designed to improve services to people of NESB, eg the Carers’ Project. Consumers and carers of NESB were observed to be told fully about services and programs, and a project is under way to develop a multilingual package of information. Service integration at the service level is the responsibility of case managers, and every client in the service, including those of NESB, is allocated a case manager. This function is suspended only in times of crisis, and here the case manager remains responsible for service integration issues.

An excellent example of the integration of client needs with program content is in the inpatient unit. A small kitchenette has been included in the design so that patients’ relatives may come in and cook, an important element in supporting a variety of cultures. A sitting room has been designed to accommodate Muslim people with prayer mats, and is used for this purpose, creating an important cultural link in an area with a high Muslim population. The family visiting room is large enough to accommodate an extended family. The overall effect is of a friendly non-institutional environment, where the needs of different cultures are specifically provided for. Criterion 8.3 promises to be met by an innovative program. Mid West AMHS is involved in a pilot project being conducted within the Western Region, which aims to provide a system of bilingual case managers for those non-English speaking consumers who have experienced difficulties in accessing services or whose treatment is impeded by lack of staff proficient in their language. Specifically, bilingual case managers are involved when the consumer expresses a preference for their involvement, there are significant cultural/language issues making assessment and/or treatment difficult, and the consumer has not successfully engaged with other clinical staff. There are three bilingual case managers employed at Mid West AMHS through this project. Together they cover Macedonian, Italian and Vietnamese languages. Their role is: • to provide information to maximise the timeliness and appropriateness of psychiatric assessments, • to act as either primary case managers or as secondary case managers (providing assistance to the primary case manager in terms of relevant cultural issues), • to educate clinicians about cultural issues, and • to facilitate education and support programs for non-English speaking consumers. The bilingual case manager interviewed saw the task as challenging, new and somewhat daunting. Given the variety of roles, and the need to meet and consult with other bilingual case managers in the region, the need is for sufficient focus to make an impact in any one of these areas, and this manager spoke of role development and prioritisation as current issues. Certainly where there is a need for bilingual workers, it may be that several may be needed in major community languages, particularly if their presence uncovers previously unmet need. Some indication of desirable ratio of workers to population, allowing for age clusters, whether migration is recent, whether people have had traumatic experiences associated with migration would allow a more rational allocation of human and other resources to achieve agreed outcomes. (Proposal for a Pilot Bilingual Case Management Program for the Western Metropolitan Region, n.d.) Mid West AMHS routinely collaborates with other bodies in many of its ventures relating to consumers from non-English speaking backgrounds, utilising the services of organisations such as ADEC and the VTPU in its training and in implementing projects. As well as these specific collaborations, Mid West AMHS has ongoing relationships with a number of organisations. For example, Mid West AMHS is represented on the Western Region Ethnic Issues Group. This group meets once every 1-2 months, and has representation from government and non-government agencies. Its brief is to

improve and advocate for services for people from non-English speaking backgrounds, and it focuses on policy, research, service access, service gaps, strategies to improve services, education, information exchange, inter-agency liaison and lobbying decision makers (Ethnic Issues Group: Terms of Reference, n.d.).

9. Service Development 9.1 MHS ensures that all staff are aware of their roles and responsibilities relating to consumers and carers of NESB. 9.2 MHS planning processes and documents specifically refer to the needs of NESB consumers, carers and communities, including the need for outreach work necessary to identify people of NESB who might benefit from MHS services. 9.3 MHS resources are allocated to ensure the achievement of service outcomes for all consumers of NESB at the same level as those for English-speaking consumers. 9.4 MHS data collection includes material relating to consumers and carers of NESB necessary for the delivery of effective and culturally sensitive services. 9.5 MHS evaluation methods make specific reference to service effectiveness for consumers of NESB. Mid West’s Policy and Procedures Manual indicates that responsibility within the Service for continuing responsiveness of services to ethnic communities will be specified and ensured in a number of ways: • through administrative structures eg Programs, Committees, Position Descriptions • specific allocation of responsibility to position incumbents eg: Area Manager to chair a forum in the Service where all managers report on culturally sensitive matters in seven designated areas, and to meet regularly with the Network’s Ethnic Mental Health Consultant; Area Manager through Program Managers to designate senior staff in each Program to liaise with each other and report to Program Manager on specifics of service responsiveness. • Within Programs, Program Managers are responsible to ensure that all staff know of the range of language services and how to access them, to ensure that staff are educated about culturally sensitive practice, as well as to ensure that bilingual abilities are desirable in new staff. Outreach work is currently being pursued through the Carers’ project which aims to develop ways of addressing the needs of careers of NESB. Resources are thus being directed to the particular needs of NESB people in order to ensure that they enjoy the same level of service as English-speaking people. The data-collecting patterns of the Service till recently have yielded only the same data as are received about English speakers, but the particular information needs of the Service about clients of NESB will be served better as the new clinical forms asking questions about language and cultural needs are used. As an example of good resourcing of staff to provide adequate and appropriate services to people of NESB, several directories are available for routine use by staff. These include the Directory of Mental Health Information in Community Languages: An Initiative of Cross Regional Multicultural Education Working Group Vic (1997). This details a

number of mental health resources, the languages into which they have been translated, the organisation from which they can be made available, and their cost (Department of Human Services 1997). In addition, workers have access to a number of directories of bilingual services (eg. Vietnamese Workers in the Western Region (n.d.), Macedonian Services (n.d.), Croatian Services (n.d.); List of Affiliated Maltese Services (n.d.); List of Bilingual Private Mental Health Practitioners, Psychiatrists (n.d.); and List of Bilingual GPs (n.d.). Other physical resources are designed to assist cultural sensitivity. For example, staff have available to them a document entitled Working with the Vietnamese Community (1996), which was prepared by Thuy Dinh from the South West AMHS. This document describes Vietnamese history and immigration, and describes in detail many of the Vietnamese cultural views associated with mental health and illness. *A Mobile Support Team worker with whom the project worker visited Vietnamese parents who were most concerned about their son’s admission to hospital. He did not offer to shake hands, but instead inclined his head politely, and did not look directly at the mother when speaking to her. He understood the parents’ references to the war conditions from which they had come, and was at pains to ensure that they understood their son’s illness as much as possible. Considerable attention is paid to inservice training in transcultural mental health. Regular inservice training sessions are conducted by the Victorian Interpreter and Translation Service, for example, to equip clinicians to work better with interpreters. Inservice training sessions are also regularly conducted by the VTPU, the Ethnic Mental Health Consultant of the NWHN and ADEC. Evaluation is integral to many of the activities of Mid West AMHS. The policy, procedure and planning documents outlined above provide a framework for regular monitoring of the achievement of specific goals and objectives, and the status of particular strategies. As an example, one of the strategies which flowed from the issues identified in Mid West Area Psychiatric Services: Demographics (n.d.) was “Clinical forms to include questions relating to language and cultural issues of clients and carers”. The document notes that this strategy has been achieved, and the evidence for this can be found in the forms themselves. For instance, the inpatient admission form asks questions relating to both the consumer and carer’s (a) language spoken, (b) language competency, (c) literacy skills, (d) command of English, and (e) cultural issues. Likewise, this document notes that “Alert stickers identifying language needs … [should be attached to the patient’s file],” and this has been achieved. In addition to this routine monitoring, an external evaluation of Mid West AMHS was conducted by Papanicolaou and Fitch, who were commissioned by the Mental Health Branch of Human Services to conduct an evaluation of all 22 AMHSs. Mid West AMHS achieved an overall rating of 77%. It should be noted that this evaluation was based on self-report and documentary evidence only, and did not involve observation of day-today practice (Papanicoulaou and Fitch, Evaluation of the Area Mental Health Services’ Response to the Needs of People from Non-English Speaking Backgrounds: Mid West AMHS, 1997).

Internal and external evaluations are also integral to specific projects conducted by Mid West AMHS. The Non-English Speaking Background Carers Project, for example, is being evaluated by a pre- and post-implementation audit conducted by ADEC. A formal evaluation is also being conducted of the Bilingual Case Management Program.

10. Documentation 10.1 MHS documentation protocols and practices relating to people of NESB comply with National Standards. 10.2 The content and purpose of all documentation relating to consumers and carers of NESB is communicated, where clinically appropriate, to the consumer and carer verbally and in writing in their preferred language. Mid West complies with the National Standard 10. It protects confidentiality in records filing and in staff practice, clinical records are individual, dated, legible (so far as could be ascertained), records of interpreter use are kept and communicated to staff, interpreter prompts are put on appropriate files and there are written protocols to be followed regarding documentation. All clients of the service have individual care plans and are assigned a case manager who manages the client’s clinical record, and ensures that other staff have access to it only on a “clinical needs” basis, eg if the CATT are involved. It was observed that staff explain to clients of NESB that their records are kept confidential. The development of multicultural information packages and their use in all of the Service’s Programs will assist compliance with 10.2.

11. Delivery of Care 11.1 MHS care, treatment and support to consumers and carers of NESB incorporates the provision of choice in location, treatment mode and treating clinician. 11.2 Treatment appropriateness, effectiveness and acceptability to each individual MHS consumer of NESB is optimised, and prioritisation of the most clinically needy is ensured. 11.3 Assessment of people of NESB at the initial contact with MHS is responsive to their specific needs in terms of cultural sensitivity, timeliness, style and location. 11.3.1 This assessment involves appropriate coordination with other services. 11.3.2 This assessment is regularly reviewed according to National Standard 11.3. 11.4 Culturally appropriate individual care plans are drawn up and regularly reviewed with consumers and carers. 11.5 MHS consumers and carers of NESB are fully informed in their preferred language about treatment options, and their informed consent is obtained before treatment proceeds. 11.6 Consumers and carers of NESB are supported by MHS in choice of the setting for treatment. 11.7 Treatment of MHS consumers of NESB is monitored for adverse side effects. 11.8 Where MHS provides treatment to consumers of NESB in an inpatient setting, information, orientation and introductions are made available in the consumer’s and carer’s preferred language.

11.9 Whilst inpatients, consumers of NESB is given assistance by the MHS to participation in cultural and/or religious practices. 11.10 Rehabilitation activities eg leisure, living skills, training are carried out in settings most appropriate to the individual MHS consumer of NESB so as to optimise access and independence. 11.11 MHS consumers of NESB are assisted to find accommodation where their cultural needs can be met. Mid West does incorporate the client’s choice of location, treatment mode and treating clinician, with several important provisos. Staff are willing to accommodate choice of location where this is reasonable and feasible eg visiting at home where the person is unable or unwilling to attend the clinic. MST clients are regularly met at home and taken out for small social outings in the community. Other preferences are considered and accommodated as far as possible, with the exception that in a crisis situation, the CATT works as a team, with any member likely to be in attendance. A young man whose mother is of NESB has schizophrenia, a personality disorder, and is a substance abuser. His mother’s culture insists that ill family members are looked after at home. However, the mother has had her life severely disrupted by the young man’s behaviour. With the mother’s agreement, the MST found appropriate accommodation for him. He has now returned home because he prefers to live there, and his mother feels obliged to accept this. The MST is working to minimise the young man’s self-destructiveness, and to support the mother in her decision to accept him back, understanding that it is culturally based. While 38% of the Service catchment area is of NESB, data on client files show that during the financial year 1995/6, 43.9% of Mid West’s clients were of NESB, a reversal of more common ratios. Assessments are performed with the assistance of an interpreter where necessary, or are referred to bilingual workers for assistance. The flexible policy of the Service regarding location applies, although Service preference is for clinic based assessment, because of the need for a number of clinicians to be involved. An assessment was observed to include intersectoral coordination, several clinicians, a community worker and an interpreter. Workers are now required to show cultural sensitivity in drawing up care plans for people of NESB. They can obtain assistance from three bilingual workers, the Culturally Sensitive Practice Coordinator, in-service sessions on cultural sensitivity, or, via the Area Manager, the Network Ethnic Mental Health Consultant. While formal review occurs on the same basis as for all clients, it was observed that staff continually review, and, if necessary, revise NESB clients’ care plans. This is done at case planning meetings held at least weekly within each Program, when a client is moving from one Program to another, when a client is moving residence, when visits are made by the MST. Carers were observed to be informed fully about changes in care plans, and asked for their input.

Consumers and carers (where appropriate) are fully informed about treatment options, and their consent obtained. This is assisted by the regular use of trained interpreters and by the appropriate deployment of bilingual staff. It will be further assisted when the multicultural information package for use in all Programs is developed and in use. The excellent standard of language and cultural sensitivity services at Mid West ensures that staff are sensitive to the issue that side effects of treatment may present differently in people from different cultures. The use of trained interpreters and the employment of bilingual workers enhance the likelihood of good communication with clients of NESB, so that a matter such as adverse side effects can be identified. The Inpatient Unit’s current Quality Plan specifies that interpreters be present on information nights and that a number of specific measures be taken to ensure that NESB inpatients are well informed. The requirement for culturally sensitive practice would ensure that the Program Manager and staff would be aware of a client’s wish to participate in cultural or religious activities. Participation would then be subject to clinical and safety criteria. The rehabilitation of NESB clients in culturally appropriate settings will be enhanced by the outcome of the Carers’ Project. Accommodation needs are met through: • the efforts of individual case managers, • continuing liaison with families and community housing organisations such as Norwood, which now has an Ethnic Worker, and • the NESB-friendly policies and activities of the Community Care Unit, where over 50% of residents were from a NESB background at the time of the case study.

5.1.3. Discussion In the Western Region of Melbourne, where the Mid West service is located, policy for ensuring NESB access to mental health services is spelled out in detail. When the criteria in the evaluation framework are applied to this level of policy, there is good coverage. Regional policy is articulated then to the level of the Area Mental Health Service as a whole. At the Service level, the excellent programs and projects of the Service related to NESB people’s access are specified, with managerial responsibility and timelines for completion specified. They are then to the Program level through Strategic Plans at each level. At these levels, the potential usefulness of the evaluation framework becomes more apparent. When an overall objective and the tasks identified as being associated with it are translated to the Program level, the whole question of inputs, outputs and outcomes become vague. For example, the Inpatient Unit specifies that all inpatients are to have access to interpreting services, to information and to special events for different ethnic groups. But how is this use to be monitored and its quality known? How does

management know if the requirement to provide this service is always met? Is this sufficient to ensure culturally sensitive interaction? How often are staff to be trained? How are the desired outcomes of good client and family communication and cultural sensitivity to be ensured? This is not to say that the Inpatient Program is deficient in these matters. However, there is no indication as to how management will understand or measure the results of the education and information provided, and no indication of the frequency of their proposed evaluation. The Strategic Plan at this level does not show precision, range and a plan for review. In a year from the date of the plan, management would be able to count the staff trained. But there is no indication as to how the outcome of the intervention would be known in terms of its enrichment of practice or improvements in diagnosis, treatment and care. Without this information, management cannot rationally plan for future activities or allocation of resources to ensure good treatment for people of NESB in the Inpatient Unit. Similarly with the MST, again a Program observed to be excellent in its readiness to use interpreters, and the sensitivity of staff to cross-cultural issues. Here the objective of improving services to NESB clients (which ones? By when? In what ways? Against what criteria?) is translated into tasks which are imprecise. Presumably the appropriate use of interpreters is known against regional and service policy. But how would managers know? And how would the quality of this intervention be known? And its impact on the client? The development of links with NESB community groups was scheduled to begin in February 1997. But what kind of program is envisaged? Over what time? With what priorities? For what purposes? The recruitment of bilingual staff wherever possible is ostensibly a good objective. But what languages are most needed? What proportion of staff should have these skills? How is success to be planned for? How measured? This may appear pedantic. However, it goes to the core of good service delivery and the most effective and efficient use of resources. Resources - human, monetary, physical - need to be allocated on a rational basis so as to maximise the implementation of policy and the building in of good practice into Programs. Appropriate allocation of resources is best made prospectively when precise, measurable goals are set and tasks devised to achieve these goals, by a specified time. Appropriate allocation of resources are best evaluated retrospectively when data has been gathered which allows the measurement or understanding of outcomes from the use of resources matched against the goals set. These activities will not occur unless there is a mechanism to ensure their occurrence. Community Mental Health Services such as Mid West are increasingly being required to account for their activities and the outcomes of their Programs. Evaluation of Programs, and of the Service as a whole, occur often. However, the fundamental focus of day to day work in the different Programs is that of service delivery to individuals. It is an environment where the urgent constantly wins out over the important, and where clinical, rather than program evaluation, skills prevail. When such a Service wants to set in place ways of measuring or understanding progress in specific areas, such as

that of provision of good access to services for people of NESB, it is essential that these ways or tools be simple and “user-friendly”. Otherwise they will gather dust. However, if such tools are to be useful in describing and then measuring whether success has been achieved, and to what extent, they must also be comprehensive, concrete, and allocate responsibility for action and timelines and criteria for performance or outcomes. Progress and achievement can then be understood on a regular basis, and prioritisation of tasks can be made in the context of larger goals. The evaluation framework fills this need. Its criteria are comprehensive. it is short and clear. Its worksheets focus on concrete information. What needs to be done? Who is responsible for doing it? By when? Under the heading of one criterion at a time, an number of related matters are covered by each sheet, thus making it easier to see the whole range of what is being undertaken in one area, such as service development, or documentation. The worksheets can be adapted to any data collection system. The whole could be stored on computer and thus made available to all staff. Or it could be stored as hard copy, with program and project descriptions attached to each relevant worksheet. Performance on specific criteria, or on the whole area of NESB access, can be easily and regularly gauged. No particular skill or expertise or training is needed for staff to understand the criteria, or for management to utilize the worksheets.

5.3. Case Study 2 Rockingham Kwinana Psychiatric Service (Perth, Western Australia) 5.3.1. Service description The Rockingham Kwinana Psychiatric Service (RKPS) has developed since 1992. It provides mental health services to people aged between 17 and 65 living in the southernmost 50 square kilometres of Perth, an area of low socio-economic status. Its component services are: •

The Alma Street Centre: This 50-bed inpatient unit is located at Fremantle Hospital. Twelve of its beds comprise a Psychiatric Intensive Care Unit

•

Acute Intensive Day Program (Day Hospital): This is a group program, in which key workers provide individual input for people with adjustment and affective disorders, with the aim of promoting their early discharge.

•

Acute Team: This team provides clinical services to new referrals requiring urgent assessment and/or input for concentrated periods of time.

•

Complex Needs Team: This team provides intensive rehabilitation to people with chronic and severe psychiatric illness.

•

Early Episode Psychosis Program (EPPIC): This program aims to reduce the morbidity associated with psychosis by early identification and appropriate management.

•

Living Skills Program: This program is designed to improve living, recreational and vocational skills, as well as to increase self-esteem and goal-setting.

In addition to these core services, RKPS works closely with other relevant services in the area to provide care to people from non-English speaking backgrounds with mental health problems. In particular, RKPS has collaborated closely with the local Division of General Practice to undertake a number of major initiatives to improve the delivery of mental health care in general practice. These include: •

upskilling of GPs to achieve a strong “shared care” focus

•

employment of a GP to deal specifically with patients with anxiety disorders

•

a “shifted outpatients” clinic in the largest general practice in the area, in which a consultant psychiatrist visits to facilitate shared care

•

regular lunchtime meetings of interested GPs to discuss mental health issues and provide mutual support.

RKPS serves a population of approximately 90,000. This has a relatively low NESB population, ranging from 0.4% in Rockingham, 1.1% of those in Kwinana, 1.4% in Melville to 6.1% in Fremantle. More recent information is that in the Rockingham/ Kwinana catchment area, NESB people constitute 6.5% of the population, 9.8% of inpatient episodes, and 10.8% of outpatient episodes. (Mental Health Services Strategic Plan, Draft 2, 1998, p10.4)

5.3.2. Rockingham Kwinana and the Evaluation Framework

There is no specific policy covering these matters. However, one of the situations where a professional interpreter must be involved is in situations involving criminal investigations.

3. Consumer and Carer Participation 3.1 MHS involves representatives of consumers and carers of NESB in all activities directed towards ensuring community input to the MHS’s policies, procedures and programs. 3.2 This involvement includes policy, procedure and program evaluation. Consumer and carer needs for the general clientele have been systematically investigated, and a number of programs set up to ensure they are met. There is now a library for members, a support group, a crisis accommodation program, a recreation officer, consumer involvement in the Early Psychosis Project Steering Committee. There is no specific reference to people of NESB in these ventures. However, a Non-English Speaking Background Project is seeking to have NESB needs met through training of health professionals in cultural sensitivity.

4. Promoting Community Acceptance 4.1 MHS promotes acceptance of NESB people with mental illness within their ethnic communities, and within the general community. 4.2 MHS works with leaders of specific ethnic communities to identify the most culturally appropriate ways to achieve destigmatisation. 4.3 MHS provides an ongoing integrated program of accurate information and appropriate education about mental illness, and services and treatments for mental illness, in ethnic community forums and on ethnic radio and television. 4.4 MHS contributes to education of mainstream health workers about ethnicity and mental illness. 4.5 MHS involves and supports consumers and carers of NESB in providing information and education to ethnic community groups and to mainstream health workers. The Non-English Speaking Background Project focuses on training of health professionals, including GPs, in cultural sensitivity and in the use of interpreters. As well, education and consciousness-raising courses have been provided to raise awareness in health professionals of issues relating to survivors of torture and trauma, and a training video made. General courses in cross-cultural issues for mental health professionals have been developed and conducted. This introduces these mental health workers to information about 66 organisations with an ethnic focus, with a description of the services they provide. The Project has developed relaxation pamphlets, translated into nine community languages, with accompanying tapes being developed. Finally, the Project has developed a program through which refugees with mental illness are assisted by appropriate volunteers in practical living skills, including getting around on public transport, filling in forms etc.

5. Privacy and Confidentiality 5.1 MHS communicates its policy about privacy and confidentiality to all consumers and carers of NESB, verbally and in writing, in the consumer’s and carer’s preferred language. 5.2 MHS protocols regarding reception practices, records, the location of clinical sessions and necessary telephone conversations about consumers are designed and communicated both to reassure consumers and carers of NESB, as well as to ensure absolute privacy and confidentiality. 5.3 The physical environment of MHS allows privacy for consumers and carers of NESB in all their dealings with MHS staff. 5.4 MHS is flexible about the location of service provision;eg home visits. While the Policy and Procedure Manual regarding NESB clients does not specifically address privacy and confidentiality, nonetheless, these considerations are cited as reasons for engaging professional interpreters. Another reason given is to ensure that patients receive accurate information. The physical layout of the Kwinana clinic does not, however, guarantee privacy and confidentiality. The waiting area is cramped, and is immediately adjacent to the receptionist who constantly receives and makes telephone calls. Most offices or working spaces occupied by clinical staff are demarcated by head height panels only, and private conversations would be difficult. A confidential consultation could occur only in one of several offices which are closed, and these appear to be allocated to individuals. The Service is very flexible about the location of service provision. In practice, this means a willingness to visit clients at home. The inpatient unit is a considerable distance from both the community clinics and clients’ homes, and so there would not be a choice in the instance of an inpatient.

English, filling out forms, getting around by public transport, and finding information. Volunteers are trained, and then matched to appropriate refugees. (Non-English Speaking Background Project, 1997)

7. Cultural Awareness 7.1 MHS maintains, and makes available to staff, current information about the variety and extent of communities of people of NESB in the catchment area. 7.2 MHS staff are trained in the cultural mores relevant to people of NESB in the catchment area. 7.3 MHS liaises with representatives of these local communities of NESB people, and with other local services, to ensure the cultural sensitivity of all aspects of service delivery to consumers and carers of NESB. Staff are informed about the 0.4% of people of NESB who live in the Rockingham area, and the 1.1% in Kwinana. Staff are trained in cross cultural issues. Considerable work has been conducted with local GPs to ensure that appropriate referrals of NESB patients are made to the Service. Yanti is a nineteen year old Muslim woman. She came to Australia two years ago from Indonesia, where she met her American husband, John. She has presented to RKPS with what is thought to be postnatal depression, having given birth to a daughter six months ago. With the assistance of an Indonesian interpreter, a psychologist determines that Yanti believes that she must have her daughter circumcised. John is opposed to this. Over a series of sessions, the psychologist works with Yanti to understand her belief system. Yanti’s conviction is based upon her understanding of the Qiran. The psychologist seeks the opinion of an Imam, a respected member of the Indonesian community, who has an alternative view of the teachings of the Qiran. His understanding is that female circumcision is not needed for acceptance. With Yanti’s permission, this man is invited to attend a session, and offer his interpretation. Yanti discusses this issue in depth with the Indonesian community member, and concludes that she does not need to have her daughter circumcised. 8. Integration 8.1 MHS policies, procedures, protocols and programs specifically related to people of NESB are communicated to all staff in MHS. 8.2 All aspects of MHS programs are available as appropriate to consumers and carers of NESB. 8.3 Each consumer of NESB has a single MHS staff member responsible for all aspects of service integration, internal and external, relating to the consumer.

The Policy Guidelines on the Use of Interpreting Services specify that it is the responsibility of the individual mental health worker to ensure that interpreters are used as appropriate as the Guidelines state. It was observed that people of NESB were catered for in all Programs, with all staff being trained in interpreter use and in cultural sensitivity. A Case Management system allocates a case manager to each patient who is responsible for all aspects of service integration. Rodriguez is a Chilean-born eighteen year old, who has been a client of RKPS for the last two years. He has a history of solvent abuse, and has had several psychotic episodes. He lives at home with his family. His mother also has had contact with the service, having received grief counselling. Until recently, Rodriguez was making considerable progress with RKPS. His solvent abuse had reduced, and his psychotic symptoms were relatively well controlled. He had been attending the Living Skills Program. He had also been for a job interview on the recommendation of the CES. Although he did not get the job, he was satisfied that he performed reasonably well at the interview. However, in late 1997 his parents returned to Chile for three months, and Rodriguez was left at home unsupervised. He coped quite well while his parents were away, but now that they are back he is rebelling against the restrictions they are placing on him. On several occasions he has returned home in the early hours of the morning, affected by solvents. With the assistance of an interpreter, Rodriguez’s case manager facilitates a meeting between him and his parents. The discussion becomes quite heated, but ultimately all parties resolve that the best solution may be for Rodriguez to find alternative accommodation. Rodriguez is also keen to pursue any employment avenues. His case manager offers to assist him in this.

The Non-English Speaking Background Project focuses on systems change. It aims to increase levels of expertise in community-based mental health services and primary care services (including GPs) to address the needs of people from non-English speaking backgrounds, primarily through training and resources. The project has involved a number of components: •

a series of general cross-cultural training sessions for mental health professionals have been developed

•

a public lecture and two half-day workshops were conducted through a nongovernment organisation, ASeTTS, which provides services for survivors of torture and trauma training in cross-cultural psychiatry has been provided for GPs.

•

11.3.2 This assessment is regularly reviewed according to National Standard 11.3. 11.4 Culturally appropriate individual care plans are drawn up and regularly reviewed with consumers and carers. 11.5 MHS consumers and carers of NESB are fully informed in their preferred language about treatment options, and their informed consent is obtained before treatment proceeds. 11.6 Consumers and carers of NESB are supported by MHS in choice of the setting for treatment. 11.7 Treatment of MHS consumers of NESB is monitored for adverse side effects. 11.8 Where MHS provides treatment to consumers of NESB in an inpatient setting, information, orientation and introductions are made available in the consumer’s and carer’s preferred language. 11.9 Whilst inpatients, consumers of NESB is given assistance by the MHS to participation in cultural and/or religious practices. 11.10 Rehabilitation activities eg leisure, living skills, training are carried out in settings most appropriate to the individual MHS consumer of NESB so as to optimise access and independence. 11.11 MHS consumers of NESB are assisted to find accommodation where their cultural needs can be met. In practice, the only choice which can be given by the Service is that of receiving a home call. The components of the Service are widely separated, and open choice of location or of treating clinician would not be feasible. Choice as to mode of treatment is constrained by clinical appropriateness. Initial assessment is required to ensure that patients of NESB are fully informed, and that an interpreter is engaged. Considerable work has been done both internally by the multicultural staff, and externally through the NESB project to ensure appropriate coordination with other services. The Case Management system and regular Case Planning Meetings ensure regular review of patient assessment. There appears to be no specific policy as to the care plans for people of NESB. However, individual care plans are drawn up by staff with access to training in cultural sensitivity, to advice from multicultural staff and to assistance from trained interpreters. Information in the patient’s preferred language using a trained interpreter is mandated by the Policy Guidelines. Choice in the setting for treatment is necessarily constrained by geography and limited resources. There is no specific requirement that treatment of NESB patients is monitored for adverse side effects. However, this is assisted by staff’s enhanced cultural sensitivity after training, and by the exclusive use of trained interpreters. In the inpatient setting, staff are obliged to use trained interpreters and to ensure that all relevant information is imparted. Here, patients’ access to religious or cultural practices is greatly assisted by the presence of a chaplain who is particularly concerned that patients have this access as needed, this is actively supported by staff. Rehabilitation for people of NESB is not specifically addressed. However, the refugeecompanion matching program is an excellent initiative in this area. Finally, accommodation is an ongoing challenge for the Service in a context where the state housing authority is reducing stock in a poor area. Accommodation for people of NESB with a mental illness is addressed at the individual client level.

5.3.3. Discussion Rockingham Kwinana carries out its service activities in an area where people of NESB are few. It is geographically widespread, and its structures and personnel reflect pragmatic adaptation to changing circumstances rather than the opportunity to plan an entire service from first principles. It exists in a city where structures and functions in community mental health centres change from area to area, and where resources are used much more opportunistically than, for example, in Melbourne. In Victoria, structures for the delivery of services to the mentally ill have radically changed over the last five years, and there is now an overwhelming focus on the provision of care and treatment in community settings. There is also a strong focus on self-sufficient area-based services, and there has been the introduction of specific policies and programs for improving mental health services to people of NESB over the past few years. However, in Perth, there seems to be a strong emphasis on utilising resources from wherever they can be found, and integrating them into service structures. Migration over the past fifty years has had very little impact on this area of Perth. Even if it had, there is little in state policy beyond the provision of language services which is directly related to people of NESB. In seizing the funding opportunity offered by the NESB Project, the Director of Rockingham Kwinana has gone beyond the immediate needs of his own constituency, though he has ensured that the benefits are experienced there to the extent that specific education programs have been attended by staff. However, there was not the level of awareness of cross-cultural issues amongst Rockingham Kwinana staff that was evident at Mid West, which is understandable, since staff do not encounter the variety and numbers of NESB people. How then can the evaluation framework assist Rockingham Kwinana, and similar centres? Firstly, the framework sets out a comprehensive set of principles for service provision. It can serve as an educational tool for management and staff. It can complement the educational programs and outreach initiatives which have been developed by the Service. The framework also provides guidelines against which an active, innovative service such as Rockingham Kwinana can develop programs adapted to their particular needs. In an area where there is a small number of NESB people living, there is an excellent opportunity to identify quite precisely the ethnic groups which may be in need of information, education, and care and treatment. The Service has a good working relationship with the Western Australian Transcultural Psychiatry Unit, and itself employs experienced bilingual staff. In this context, projects, even modest ones, can be identified, initiated, progressed and evaluated with the confidence that they are relevant, targeted and an effective use of resources. The framework will be just as useful in this setting, even though its use may be quite different from that in Mid-West. In its structure and content, the Framework invites adaptation to local circumstances. Its power lies in the breadth and comprehensiveness of its content, and its emphasis on the concrete, the achievable, the need to convert vague ideals into appropriate, resourced tasks, which are then evaluated regularly against initial goals.

5.4. Case Study 3: Princess Alexandra Hospital and District Mental Health Service Brisbane Queensland

5.4.1. Service description The Princess Alexandra Hospital and District Mental Health Service (PAH&DMHS) services a catchment population of 350,000 people in the south of Brisbane. In its current form, the service has been operating since 1996 only. Primarily an adult service, it comprises an inpatient service, and four community-based teams (Coorparoo, West End, Inala and Mt. Gravatt). All operate separately, but Inala and Mt. Gravatt share a team leader. These teams work together in an integrated fashion to maximise continuity of care. In addition, there is an Assessment and Acute Care Team which provides a short-term, primarily centre-based assessment and treatment service to clients in the community who are known to PAH&DMHS. Housing and support services are also available. The service’s structure is based on a matrix model described in Table 3 below.

Table 3: Matrix structure of Princess Alexandra Hospital and District Mental Health Service Cooparoo West End Inala/Mt Gravatt T1 T2 T3 T4 T5 T6 T7 Assessment and Acute Care Inpatient Housing and Support The inpatient unit comprises 80 adult beds, and is based at Princess Alexandra Hospital. This unit is planned to undergo considerable redevelopment, including physical redesign, relocation of 24 beds, and an intensive care suite. In addition to these adult services, there are 16 beds in the inpatient unit reserved for psychogeriatric care, and a psychogeriatric community team. The ethnic make-up of the service’s catchment area is diverse, with particular ethnic groups being represented in the different team locations. For example, West End has a broad cultural mix, with many people from Greek, Italian, Dutch and other European countries. Inala has large Vietnamese and Chinese populations. Mt. Gravatt also has Chinese, Croatian and Greek populations, with high numbers of second and third generation migrants. Coorparoo, by contrast, has far fewer people from non-English speaking backgrounds, with the majority of their populations being Australian-born and/ or English-speaking.

5.4.2. Princess Alexandra and District Mental Health Service and the Evaluation Framework

1. Rights 1.1 People of NESB have the right to be informed of their rights and responsibilities as consumers of the MHS: 1.1.1 as soon as possible after entry to the service 1.1.2 verbally and in writing 1.1.3 with the assistance of accredited interpreters 1.1.4 and to be provided, in an understandable form, with information about mental illness, available services and treatment options. The Queensland Transcultural Mental Health Centre’s (QTMHC)’s Procedures are the basis for practice in the Service, and recommend that any person identified as needing an interpreter be supplied with an accredited interpreter at first and subsequent clinical sessions. Information should be given verbally and in writing in the client’s preferred language. In practice, mental health workers in the Service acknowledge that since TIS requires 24 hours notice of the need for an interpreter, it can be a matter of chance whether an appropriate interpreter is available at all times when needed, especially at initial assessments and in emergencies. PAH&DMHS has an open-ended budget with regard to interpreter use, regularly making use of the services of TIS, and primarily using interpreters who have specific training in mental health (Mental Health Interpreters, n.d.). Approximately $18,000 per annum is spent on interpreters. Some teams have developed strategies to optimise their use of interpreters. At Inala, for example, the medical staff have made an effort to see their Vietnamese clients on the same afternoon, block-booking interpreters in advance. In certain situations, the service acknowledges that it is difficult to arrange for an interpreter. Staff cited emergencies and/or first assessments in the hospital or the community setting and brief encounters in the hospital setting as particularly problematic, given the need for 24 hour notice. In these situations, staff may use telephone interpreters, but still sometimes “make do” with informal interpreters (i.e. family and friends), bilingual staff, and pictorial translation sheets. Information on the availability of interpreter services is presented in reception areas of the component services of PAH&DMHS. As noted above, routine use is now being made of the “Interpreter Required” stickers on the Individual Treatment Plans. Staff report anecdotally that some difficulties still arise, because the exact language group cannot always be identified (e.g. in the case of particular dialects). Some staff have refined the use of this sticker so that if they engage an interpreter who is really good, that person’s name is noted and they are specifically sought in future instances. Use of the “Interpreter Card” is not yet so widespread.

Increasing use is being made of the “Checklist for Persons Born in Non-English Speaking Countries”. As this is more routinely adopted, it will be possible to monitor the extent to which interpreters are being used in key clinical encounters (such as assessment and diagnosis etc).

2. Safety 2.1 MHS consumers of NESB receive support and/or treatment (where appropriate) which protects them from any abuse and exploitation. 2.1.1 This includes abuse and/or exploitation perpetrated by other consumers, service staff members, other health service staff, family members or members of their ethnic community. 2.2 Support should include access to a staff member of the client’s gender, if requested and if possible. While there are no specific Service policies which mandate these, the state Minimum Service Standards require that each patient’s right to privacy, dignity and confidentiality is recognised and respected. In practice, this is more easily achieved where an accredited interpreter is involved, so that circumstances where family of friends or untrained persons must interpret lay the ill person of NESB open to potential abuse.

3. Consumer and Carer Participation 3.1 MHS involves representatives of consumers and carers of NESB in all activities directed towards ensuring community input to the MHS’s policies, procedures and programs. 3.2 This involvement includes policy, procedure and program evaluation. This area is not addressed in the state’s Minimum Standards. QTMHC established a Non-English Speaking Background Consumer and Carer Advisory Group in 1997, which now provides input to policies, programs and services generally within the government mental health sector in Queensland. The Ethnic Mental Health Program works with the Service, but not as a conduit for such participation. There is no community focus provided by the community mental health service for carer and consumer participation in policy and service development in the specific areas covered by this community mental health service.

illness, in ethnic community forums and on ethnic radio and television. 4.4 MHS contributes to education of mainstream health workers about ethnicity and mental illness. 4.5 MHS involves and supports consumers and carers of NESB in providing information and education to ethnic community groups and to mainstream health workers. The service is well supported by the Ethnic Mental Health Program, auspiced by a nongovernment organisation known as the Queensland Association for Mental Health. This program provides expertise and co-ordination in the area of ethnic mental health to service providers and ethnic communities. It aims to improve the appropriateness of referral and treatment, and to promote awareness and acceptance. Bilingual workers from the Ethnic Mental Health Program service five communities (Greek, Vietnamese, Italian, Spanish-speaking and Chinese), and work closely with PAH&DMHS’s case managers to support consumers (Ethnic Mental Health Program, n.d.). The Croatian Mental Health Service fulfils a similar role, and is also well-utilised by PAH&DMHS. PAH&DMHS works closely with the Queensland Program of Assistance to Survivors of Torture and Trauma (QPASTT), which has a counselling, support and advocacy role. Clear lines of communication have been established between the two services, and cross-referral is common (Queensland Program of Assistance to Survivors of Torture and Trauma Inc., n.d.). Support is also provided through the Secondary Clinical Support Service, run by the QTMHC. This service uses a brokerage model and telemedicine to assist mainstream mental health staff throughout Queensland to provide services to people from nonEnglish speaking backgrounds with mental health problems. 5. Privacy and Confidentiality 5.1 MHS communicates its policy about privacy and confidentiality to all consumers and carers of NESB, verbally and in writing, in the consumer’s and carer’s preferred language. 5.2 MHS protocols regarding reception practices, records, the location of clinical sessions and necessary telephone conversations about consumers are designed and communicated both to reassure consumers and carers of NESB, as well as to ensure absolute privacy and confidentiality. 5.3 The physical environment of MHS allows privacy for consumers and carers of NESB in all their dealings with MHS staff. 5.4 MHS is flexible about the location of service provision; eg home visits. Communication about privacy and confidentiality is not specifically required. However, the policy of engaging accredited interpreters , especially at key points in the client’s engagement with the Service, would assist this. Confidentiality is assisted by the conducting of clinical interviews in closed offices, and the storing of records in locked cabinets. Home visits are regularly made to MST clients, and can be negotiated with other clients. Inpatients are seen in the inpatient unit. However, their families may be seen at home, where this is preferred.

Mr Zhang Lin is a 56 year old Chinese man who came to Australia about 40 years ago, with his family. His father has since died, leaving his mother and an older sister and brother.

Mr Zhang worked as a carpenter until he became psychotic in his 40s. After the onset of his illness, he moved home to live with his mother. He remained in her home until two years ago, when she became unable to cope with his violent outbursts. Since then, he has lived in a hostel. The bilingual mental health worker is called to visit Mr Zhang by the hostel manager. This manager says that he has had an altercation with another resident, involving physical violence. Mr Zhang knows the bilingual mental health worker well, having been a regular client of hers for over a year. The bilingual mental health worker sees Mr Zhang alone, and asks him to describe what happened. He explains that the other resident stole his cigarettes. He feels this was unfair, particularly since he is normally very generous and shares anything he has with the other residents. He acknowledges that hitting the other resident was not the best way to solve the problem, but explains that he gets very frustrated. His frustration is exacerbated by communication difficulties. His command of English has deteriorated since the onset of his illness, and neither the staff nor the other residents at the hostel speak his native language. The bilingual worker spends some time with Mr Zhang, developing some anger management strategies. She asks him to consider these strategies if a similar situation arises during the next 24 hours. She also asks him if he would like her to contact his mother and suggest that she visit him during the next few days. He is very fond of his mother, but doesn’t like making demands of her himself, and therefore accepts the offer willingly. The bilingual mental health worker agrees to visit Mr Zhang again the next day. After the bilingual mental health worker and Mr Zhang part, she goes to see the hostel manager. She asks him to monitor Mr Zhang’s behaviour, and lets him know that she will be contacting Mr Zhang’s mother. As she leaves, she gives the hostel manager a business card, and invites him to call her if he has any questions or requires her assistance. The QTMHC’s “Train the Trainer” workshops in “Managing Cultural Diversity in Mental Health” have been used by Service Management to train six senior staff who then return to their team and continue training others. Two subsequent workshops have been conducted, with training for all staff compulsory. Liaison with local NESB communities appears to be more at the informal level promoted by bilingual mental health workers than in any structured form. On-the-ground support varies from team to team. Inala, for example, has a lot of community resources, including a local community centre with a multicultural worker, a legal aid service which has an afternoon on which a Vietnamese interpreter is blockbooked, and a police station with a Vietnamese police officer. Direct support services for families and carers are limited for people from non-English speaking backgrounds, although improvements are becoming apparent. In the past,

for example, staff were reluctant to refer families and carers from non-English speaking backgrounds to organisations such as the Schizophrenia Fellowship and the Association for Relatives and Friends of the Emotionally and Mentally Ill (ARAFEMI), but this is changing. Within the PAH&DMHS itself, a version of a regular Family Support Program has now been developed and run for people of Chinese background (with the assistance of the bilingual mental health worker). Likewise, greater representation of people from non-English speaking backgrounds on advisory groups is becoming apparent. There are plans, for example, to set up a servicewide reference group, and this will include representation from ethnic communities.

outcome measures. This would be an opportunity to include criteria related to people of NESB. An evaluation has been made of the Bilingual Mental Health Worker Program. PAH&DMHS recognises that poor quality data has implications for the service’s ability to gain an overall picture of its client population, as well as implications for service delivery to the individual. To date, the information which has routinely been collected on people from non-English speaking backgrounds at PAH&DMHS has been less than optimal. The Intake Registration Form, for example collects details on birthplace, ethnicity, primary language, and whether an interpreter is required, but clinician compliance with completing these fields is poor, and the categories are broad. This problem has been compounded by the fact that there has been no consistent case register that enables people to be tracked across the different components of the service. Queensland Health is currently working on developing and implementing a comprehensive data collection system known as the Client Event Systems Application (CESA), which will join hospital and community data. This database will routinely collect the information recommended in Procedures for Persons of Non-English Speaking Background (1997), namely country of birth, main language other than English spoken at home, and whether an interpreter is required. Efforts are also being made to include this information on other forms. As well as these moves to improve information provision about PAH&DMHS’s nonEnglish speaking client base, there is also an increasing recognition that insufficient information is known about the demographic makeup of the overall service catchment area. Better use of Census data, and the conduct of formal needs assessments are seen as potential solutions. PAH&DMHS has made good use of the “Managing Cultural Diversity in Mental Health” train-the-trainer workshops offered by the QTMHC. This training augments the Resource Kit for Persons of non-English Speaking Background (1997), which contains materials to assist services meet the recommended requirements, and includes instruction in the use of interpreters. Six senior staff have undertaken training, with a view to ensuring that each team has at least one key person who can then go back and conduct workshops with his/her team, and ensure that optimal use is made of the Resource Kit. Two workshops have subsequently been conducted for staff within the service. Training for all staff has been made compulsory. Sessions have been well attended, with the majority of staff now having received training. The Chinese bilingual mental health worker has been particularly instrumental in delivering inservice training. PAH&DMHS conducts regular evaluations of its service components. As part of this ongoing monitoring, clinical record audits are planned. Such monitoring clearly enables evaluation of the extent to which mandated guidelines for service delivery to people of NESB are observed. For example, the clinical record audits could include monitoring of the appropriate use of the “Checklist for Persons Born in Non-English Speaking Countries”.

A specific evaluation has been conducted of the Bilingual Worker Program, using interviews with consumers and carers, interviews with community workers, focus groups with mental health staff, an interview with the bilingual mental health worker herself, and a file audit. The evaluation was very positive, with all sources indicating that the program was highly valued and had benefits.

11.10 Rehabilitation activities eg leisure, living skills, training are carried out in settings most appropriate to the individual MHS consumer of NESB so as to optimise access and independence. 11.11 MHS consumers of NESB are assisted to find accommodation where their cultural needs can be met. Queensland Health’s Minimum Service Standards for Mental Health Services in Queensland (1993) is the basis for service delivery standards in Queensland related to mental health . These Standards outline requirements to ensure that: • each patient’s right to privacy, dignity and confidentiality is recognised and respected; • assessment is appropriate and timely; • treatment is individualised and conforms to “best practice”; • regular patient reviews are undertaken; • discharge is planned to ensure continuity of care; • organisational structures promote effective and specialised mental health patient care; and • staffing levels and skills ensure the effective provision of specialised mental health services for patients. ongoing legislative requirements are met. For each of these standards, certain minimum requirements are outlined. Some of the requirements in the Minimum Service Standards for Mental Health Services in Queensland (1993) and the criteria in the National Standards for Mental Health Services (1996) refer explicitly to people from non-English speaking backgrounds. For example, under the first Standard (respecting privacy, dignity and confidentiality) in the former document, one of the minimum requirements is “Mental health professionals provide care which respects gender, age, disability, cultural needs, and religious beliefs”. Other minimum requirements refer only implicitly to the needs of people from nonEnglish speaking backgrounds. For example, another minimum requirement for meeting the standard of privacy, dignity and confidentiality is “Each service has a clearly outlined and publicly available procedure for handling complaints and grievances”. For complaints mechanisms to be “publicly available” to people from non-English speaking backgrounds, they must be accessible in a language that the person can understand. A Manual of Procedures, together with a Resource Kit, have been developed by the Queensland Transcultural Mental Health Centre (QTMHC). These put the Minimum Service Standards into the context of service delivery for people from non-English speaking backgrounds (Procedures for Persons of Non-English Speaking Background, 1997). The Resource Kit for Persons of non-English Speaking Background (1997) contains materials to assist services meet the recommended requirements. At PAH&DMHS, choice of location, treatment mode and treating clinician is severely constrained by availability of staff, and by guidelines developed for staff safety. Efforts are made by clinical teams to match workers with clients linguistically, but this is difficult to achieve always. Home visits are made by the Acute Team members up until 10 pm each day. This team reviews treatment plans twice daily. For clients with less acute needs, assessments and treatment plans are reviewed at least every three months. Initial assessment and plans for treatment of clients is made with interpreters present if

possible, with full explanations and information given to the client and carer. However, if an accredited interpreter is not available, bilingual staff may assist. Choice in the setting for treatment depends on the client’s clinical condition, as well as on the client’s address, the need for a specific bilingual worker, and the time of day. Rehabilitation and accommodation needs of NESB people are assisted by excellent liaison with community organisations.

5.4.3. Discussion This Mental Health Service provides a distinct contrast with Case Studies 1 and 2. Like Mid-West, it has pockets of high NESB population. Like Rockingham Kwinana, it is multi-site, provides services over a considerable area, and is very new in its present configuration. Like Mid West, but unlike Rockingham Kwinana, it can utilise excellent local policy and practice guidelines in order to assist its work in providing good access to local people of NESB. Unlike Western Australia, Queensland has a government policy regarding mental health services and people of NESB which goes well beyond the narrow conceptualisation of need in purely language terms. The Policy Statement summarises other issues around the migration experience, the distribution of NESB people throughout Queensland and cross cultural communication in assessment and diagnosis. It specifically addresses strategies related to: • appropriate staffing and staff training • language services • translations • community education and support • community participation and planning • data collection • service standards • survivors of torture and trauma • women • rural and remote communities. This comprehensive policy has been complemented in Queensland by an excellent Resource Kit for Persons of NESB. This comprises guides to local services which can assist the mental health practitioner provide good services to NESB clients. It includes information about accessing interpreters, the Queensland Ethnic Affairs Directory, central or statewide mental health services and the government Policy Statement. In this context, the Alexandra Service has considerably more resources to draw on than the Rockingham Kwinana Service, and even, in the availability of the Resource Kit, than mid West. The evaluation framework would allow this service to pursue the wider goals set out in policy, and maximise the utility of the Resource Kit. Policy goals inevitably require translation at the local level, and already the Kit has been used to achieve this, for example in the use of “interpreter” stickers on appropriate files. At a

wider level, the value of bilingual workers is clearly recognised, and their use targetted to populations. Where knowledge of local ethnic populations is inadequate, this is being recognised and targetted for change. However, there is still much to be done in consulting with ethnic community leaders,clients and carers about programs and their delivery, and in using a variety of media to convey information about mental illness and about mental health services in community languages. In this situation, where innovative practices are being encouraged and are already in evidence (even if not fully developed), the Evaluation Framework allows both a rational planning process, prioritised against the Criteria and a ready and simple tool for recording and measuring progress. Far from being superfluous, the Framework supplies a vital missing link which sits between the broad dicta of policy, and the day-to-day directory type information supplied by the Kit. It invites translation to the very different local areas covered by the service of principles which can be more easily expressed as measurable and effective activities, projects and programs.

CHAPTER 6 CONCLUSION The National Mental Health Strategy aims, among other matters, to ensure that care and treatment for severe mental illness is equally available to everyone in Australia without discrimination or impediment. Research has shown that more recent arrivals, and people who are uncomfortable with or unable to communicate in English (referred to in this report as NESB people) are not gaining access to these services at the rate they should. Government policy, at Commonwealth and State levels, is clear that the onus for providing these services on the basis of clinical need alone rests on service providers. Service providers in area or community mental health services have been working in an environment of fundamental change over the past five years. Older-style inpatient care and treatment was characterised by long stays and withdrawal from the community. A shift to community-based care for even the severely ill is taking place, albeit at a very uneven rate, across Australia. In this context, splendidly egalitarian and comprehensive policies have been developed alongside a service reality characterised by confusion, low morale and increased workload. As these changes become more established, however, services are looking for ways to ensure good practice with a most diverse range of clients, within limited resources and without the unnecessary duplication of effort. This project has identified Language, Lack of appropriate information about mental illness and mental health services, Poor communication, Stigma, and Cultural differences between client and clinician as major barriers to access to timely and appropriate mental health services across Australia. In our society, where approximately one in four people is from a culture other than British, it is imperative that the gap between policy and practice in these areas is systematically closed. The exclusive use of trained interpreters must be the rule in clinical encounters. Cross-cultural training of staff must be an ongoing feature of staff development programs. The employment of staff whose linguistic skills match local needs should be ensured by management. Sensitivity to issues of culturally-based stigma must be balanced with the need for mental health services to be visible, known and valued. Within mental health services, the individual client’s needs must be paramount. Clinicians must see cultural sensitivity and empathy as intrinsic to professional expertise and best practice. An evaluation tool cannot of itself bring about these changes. However, an effective and user-friendly tool can be used by management in a mental health service as a checklist against which performance can be measured and understood. The evaluation framework outlined here can play a most helpful role in bridging the access gap. Services have a skill base which is clinical and administrative, and firmly set in the tradition of western medicine. People of non-English speaking cultures’ languages, world views, and social expectations and demands make it difficult for them to take effective initiatives in gaining access to services they need. For busy clinicians and administrators, the framework sets out the relevant issues and

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areas where development is needed. It shows what needs to happen. This can then be readily translated to the needs of the local level and expressed as concrete tasks. These tasks or activities can be resourced, prioritised, allocated, performed and evaluated regularly as appropriate. They can be specific to a service program, or service wide. Existing activities can similarly be understood and recorded and evaluated, with a minimum of administrative or specialist input. The framework is educational, comprehensive, informed by the issues about NESB access which still exist and adaptable to any size or structure of service. Above all, as the evaluations of the services covered in the Case Studies show, it can be used as a starting point to make a good service better, and, eventually, excellent, in service provision to its NESB population. As a system of strategic planning, the evaluation framework fits with the National Mental Health Standards which now provide the nationally recognised benchmark for good practice in Mental Health. The evaluation framework complements the National Standards, providing National Standards for provision of good mental health service access to people of NESB. It is a mechanism by which any mental health service in Australia could reliably understand its standing at any time in the provision of effective service access to its non-English speaking community. Models of good service provision to people of NESB have been developed in the past. This model is distinguished by the fact that it derives from nationally agreed policy, it is not owned by one organisation or appropriate to one area or structure or size. It is informed by comprehensive research and offers an academically respectable method of evaluation. Yet it is simple, short, easily understood and applied, and can achieve for any and every community mental health centre in Australia a clear picture and program for improving access to their services for people of NESB.

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APPENDICES APPENDIX 1.: Criteria for Best Practice in the Provision of Access to Public Mental Health Services for People of NESB Throughout Australia INTRODUCTION Throughout Australia, people of non-English speaking background (NESB) use public mental health services (MHS) to an extent which fall far short of the proportion these people comprise of the population as a whole. The following criteria have been developed for use by MHS to improve the access which people of NESB in service catchment areas have to achieve best practice in providing access to its services for clients of NESB, rather than to ensure accountability. Research has identified a number of barriers to access to MHS by people of NESB. These include:

• lack of access to information about mental illness and mental health services in languages other than English • •

lack of access to language assistance in the clinical setting

culturally specific understandings of the meaning and significance of symptoms of mental illness and of appropriate treatments and care

• lack of training for MHS staff about these understandings with adverse consequences for assessment, diagnosis and treatment •

a focus by clinical staff on the assumptions and methods of western-style psychiatry

• •

non-involvement of people of NESB in service planning and evaluation

•

rigidity in modes of service provision

persistent and widespread stigma attached to mental illness in specific NESB communities

National standards for MHS, endorsed by the Australian Health Ministers Advisory Council, were released in January 1997 for use by all Australian public MHS. They are used as the basis of these criteria for best practice with mental health clients of NESB because: • they have been agreed by all states/territories • they apply to all public MHS • they will be known to all service providers • they apply to services to all clients, including those of NESB • they set the standard for best practice in Australia • they can address the issues outlines above. Recurring themes in these Standards of particular relevance to people of NESB

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include:

•

the need for documentation - of consumer contacts, of policies, protocols and procedures

•

practice which is consumer-centred and which integrates other services both internally and externally

• evaluation and review - both of individual service plans and of the whole service •

the need for a two way information flow - to and from the consumer, carer and community

•

priority in service provision to be given to those most in need of services.

The criteria build on these Standards, and provide and interpretation of their application to mental health service delivery to people of NESB. HOW TO APPLY THE CRITERIA The criteria have been developed for use in mental health primary service delivery centres, where mentally ill people of NESB form part of the targetted service population. They are therefore most applicable to situations of direct consumer contact, rather than to services where secondary or tertiary consultancy is a major focus. The worksheets for recording the degree of matching with the criteria are adapted from the worksheets published with the National Standards, on the basis that service providers will be building familiarity with these. No new expertise will be needed to use the worksheets, and the data obtained will be directly comparable with other data collected by the service via the National Standards worksheets. Accuracy of comparison will be enhanced if the same person fills the worksheets at successive evaluation dates. If this is not possible, then the incumbent of the same position, eg the manager, should do so each time, using the same kind of data supplied by workers’ standard records. The rating codes are those used in National Standards worksheets, with the proviso that individual services may wish to cross reference the data on future service improvements either to their own attached documents, or to other service records which they keep for the purposes of ongoing service evaluation and quality improvement. This could be particularly useful where a criterion is partially met, or not met, so that proposed remedial action or service development can be recorded and subsequently evaluated. As the National Standards point out, the use of the A or Attained rating indicates the achievement of a specific criterion with the recognition of the need for ongoing

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three months, so that staff can be kept informed and corrective action can be taken speedily where appropriate. THE CRITERIA 1. Rights 1.1 People of NESB have the right to be informed of their rights and responsibilities as consumers of the MHS: 1.1.1 as soon as possible after entry to the service 1.1.2 verbally and in writing 1.1.3 with the assistance of accredited interpreters 1.1.4 and to be provided, in an understandable form, with information about mental illness, available services and treatment options. 2. Safety 2.1 MHS consumers of NESB receive support and/or treatment (where appropriate) which protects them from any abuse of exploitation. 2.1.1 This includes abuse and/or exploitation perpetrated by other consumers, service staff members, other health service staff, family members or members of their ethnic community. 2.2 Support should include access to a staff member of the client’s gender, if requested and if possible. 3. Consumer and Carer Participation 3.1 MHS involves representatives of consumers and carers of NESB in all activities directed towards ensuring community input to the MHS’s policies, procedures and programs. 3.2 This involvement includes policy, procedure and program evaluation. 4. Promoting Community Acceptance 4.1 MHS promotes acceptance of NESB people with mental illness within their ethnic communities, and within the general community. 4.2 MHS works with leaders of specific ethnic communities to identify the most culturally appropriate ways to achieve destigmatisation. 4.3 MHS provides an ongoing integrated program of accurate information and appropriate education about mental illness, and services and treatments for mental illness, in ethnic community forums and on ethnic radio and television. 4.4 MHS contributes to education of mainstream health workers about ethnicity and mental illness. 4.5 MHS involves and supports consumers and carers of NESB in providing information and education to ethnic community groups and to mainstream health workers.

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5. Privacy and Confidentiality 5.1 MHS communicates its policy about privacy and confidentiality to all consumers and carers of NESB, verbally and in writing, in the consumer’s and carer’s preferred language. 5.2 MHS protocols regarding reception practices, records, the location of clinical sessions and necessary telephone conversations about consumers are designed and communicated both to reassure consumers and carers of NESB, as well as to ensure absolute privacy and confidentiality. 5.3 The physical environment of MHS allows privacy for consumers and carers of NESB in all their dealings with MHS staff. 5.4 MHS is flexible about the location of service provision: eg home visits. 6. Prevention and Mental Health Promotion 6.1 MHS ensures that information relating to prevention and to early detection of mental illness is communicated to the different ethnic communities in the MHS catchment area in a variety of media and locations. 6.2 MHS works with individual consumers and carers to make plans in the event of a relapse. 6.3 MHS workers maintain active liaison with ethnic community leaders so that they make appropriate referral of people of NESB to MHS. 7. Cultural Awareness 7.1 MHS maintains, and makes available to staff, current information about the variety and extent of communities of people of NESB in the catchment area. 7.2 MHS staff are trained in the cultural mores relevant to people of NESB in the catchment area. 7.3 MHS liaises with representatives of these local communities of NESB people, and with other local services, to ensure the cultural sensitivity of all aspects of service delivery to consumers and carers of NESB. 8. Integration 8.1 MHS policies, procedures, protocols and programs specifically related to people of NESB are communicated to all staff in MHS. 8.2 All aspects of MHS programs are available as appropriate to consumers and carers of NESB. 8.3 Each consumer of NESB has a single MHS staff member responsible for all aspects of service integration, internal and external, relating to the consumer. 9. Service Development 9.1 MHS ensures that all staff are aware of their roles and responsibilities relating to consumers and carers of NESB. 9.2 MHS planning processes and documents specifically refer to the needs of NESB

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and communities, including the need for outreach work necessary to identify people of NESB who might benefit fromMHSs. 9.3 MHS resources are allocated to ensure the achievement of service outcomes for all consumers of NESB at the same level as those for English-speaking consumers. 9.4 MHS data collection includes material relating to consumers and carers of NESB necessary for the delivery of effective and culturally sensitive services. 9.5 MHS evaluation methods make specific reference to service effectiveness for consumers of NESB. 10. Documentation 10.1 MHS documentation protocols and practices relating to people of NESB comply with National Standards. 10.2 The content and purpose of all documentation relating to consumers and carers of NESB is communicated, where clinically appropriate, to the consumer and carer verbally and in writing in their preferred language. 11. Delivery of Care 11.1 MHS care, treatment and support to consumers and carers of NESB incorporates the provision of choice in location, treatment mode and treating clinician. 11.2 Treatment appropriateness, effectiveness and acceptability to each individual MHS consumer of NESB is optimised, and prioritisation of the most clinically needy is ensured. 11.3 Assessment of people of NESB at the initial contact with MHS is responsive to their specific needs in terms of cultural sensitivity, timeliness, style and location. 11.3.1 This assessment involves appropriate coordination with other services. 11.3.2 This assessement is regularly reviewed according to National Standard 11.3. 11.4 Culturally appropriate individual care plans are drawn up and regularly reviewed with consumers and carers. 11.5 MHS consumers and carers of NESB are fully informed in their preferred language about treatment options, and their informed consent is obtained before treatment proceeds. 11.6 Consumers and carers of NESB are supported by MHS in choice of the setting for treatment. 11.7 Treatment of MHS consumers of NESB is monitored for adverse side effects. 11.8 Where MHS provides treatment to consumers of NESb in an inpatient setting, information, orientation and introductions are made available in the consumer’s and carer’s preferred language. 11.9 Whilst inpatients, consumers of NESB is given assistance by the MHS to participation in cultural and/or religious practices. 11.10 Rehabilitation activities eg leisure, living skills, training are carried out in settings most appropriate to the individual MHS consumer of NESB so as to optimise access and independence. 11.11 MHS consumers of NESB are assisted to find accommodation where their cultural needs can be met.

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Appendix 2: Project Contacts

Contacts in the NESB Project Local Reference Group Name Paris Aristotle

Description Director Foundation for Survivors of Torture, Victoria

Type of Contact Telephone Reference Group

Malina Stankowska

Executive Director, Action on Disability within Ethnic Communities, Victoria

Reference Group Interview

Val Gerrand

Manager, Client Services Psychiatric Services Branch, Melbourne

Telephone Reference Group

Kali Paxinos

Schizophrenia Fellowship of Victoria, Fitzroy

Reference Group Interview

Tony Blanco

Waratah Area Mental Health Service, Moonee Ponds

Reference Group

Isabel Collins

Victorian Mental Illness Awareness Council, Brunswick

Reference Group

Trish Saunders

Manager, MWCMHC, St Albans

Telephone Interview

Peter Wellington

Co-Ordinator ATMHN, Fitzroy

Reference Group

National Reference Group Name

Description

Type of Contact

Peter Kunst

Director, The Migrant Mental Health Services, South Australia SANE Australia, Victoria Director, Transcultural Mental Health Centre, NSW Coordinator, Queensland Transcultural Mental Health Centre Manager, Multicultural Health, NSW Department of Health

Interview Reference Group Reference Group Reference Group

Barbara Hocking Abd Malak Ivan Frkovic Michael Kakakios

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Reference Group Reference Group

Steering Committee Name Lucio Naccarella Michael Summers David Dunt Jane Pirkis

Steering Committee Steering Committee Steering Committee Steering Committee

Other Contacts Made Name

Description

Type of Contact

Spiro Pandelakis Anne Ah Hiouh Cutler Dr Maria San Pedro Marnie Bower

Transcultural Mental Health Centre NSW Letter Community Nurse, Dementia Day Care TAS Letter Medical Officer, The Tamarind Centre NT Letter Senior Project Officer Department of Community and Health Services, TAS Letter Dr Ida Kaplan Director of Clinical Services, Foundation for Survivors of Torture, Victoria Letter Dr Salvatore Febbo Director Transcultural Psychiatry Unit, WA Letter Deb Milner Director of Access & Standards Section, Mental Health Branch, Commonwealth Letter Prof. Beverly Raphael Director of Mental Health, NSW Health Dept. Letter Mark Loughheed Multicultural Mental Health Access Program, SA Meeting Attended Ernie Soruini North West Adelaide Mental Health Service, ‘Acis’, SA Meeting Attended Mario Yirgili Services to the Elderly, Hillcrest, North West Region, SA Meeting Attended Adolyn Prince Team Resourcer for Assessment & Acute Care Interview Janet Martin Team Leader of Mt Gravatt & Snalen, QLD Interview Shirley Wiggan Service Development Coordinator, PAH + DCMHC Interview Ram Raja Clinical Nurse Consultant PAH + DCMHC Interview Yvonne Stolk Ethnic Mental Health Consultant, North West Region, Victoria Interview Liz Gallois Health Services Commissioner’s Office, VIC Interview Spase Velanovsky North Eastern Association for the Mentally Ill, Melbourne Interview Penny Mitchell Transcultural Mental Health Centre, NSW Interview Catherine Stephenson Rockingham/Kwinana Area Mental Health Service, Perth Interview Angela Romas Consumer, Victoria Interview Francis Acquah North Eastern CATT, Melbourne Interview Vung Nguyen Springvale Mutual Assistance Association, VIC Interview

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Name

Description

Type of Contact

Rita

Bilingual Worker, Stigma Project, WA

Interview

Rafael

Bilingual Worker, Stigma Project, WA

Interview

Krissa O’Neill

Director, Stigma Project, WA

Ria Strong Pat O’Brien

Interview Meeting Attended Interview Telephone

Consumer Manager, Ethnic Health Policy Unit, Queensland Department of Health Interview Debbie McBryde Nurse Manager, Mid West Community Health Centre, (MWCMHC) Inpatient Unit Interview Peter Kelly Nurse Manager, MWCMHC, Community Care Units Interview Simon Bretnall Nurse Manager, MWCMHC, Mobile Support Team Interview Scott McBurnie Nurse Manager, MWCMHC, Crisis & Treatment Team Interview Trish Altieri Nurse Manager, MWCMHC, Continuing Care Treatment Interview Sandra Leone Women’s Health in the North Telephone Alisia Fiorito Consumer, Melbourne Telephone Dr Bernadette Wright Transcultural Psychiatry Unit, WA Telephone Helen Troy Nurse Manager, Princess Alexandra & District Community Hospital Mental Health Care Telephone Interview Ralph Hampson Psychiatric Services Branch, Department of Human Services, Victoria Telephone Hass Dellal Australian Multicultural Foundation Ltd. Executive Director Letter Mirta Gonzalez Director, Centre for Ethnic Health Victoria Telephone Rhonda Galbally CEO Victoria Health Promotion Foundation Telephone Steven Ziguras Service Development Officer Victorian Transcultural Psychiatry Unit Meeting Attended Michelle Harris TRANSACT, ACT Telephone Renee Grympa South Australian Survivors of Torture and Trauma Association Interview Tindaro Fallo Migrant Health Services of South Australia Interview Jenny Luntz Project Officer, Young NESB People, VIC Interview Silvio Iadarola Services to the Elderly, Norwood, SA Meeting Attended Julie Goodes Services to the Elderly, Norwood, SA Meeting Attended Ho Le Youth Parent Services, Adelaide, SA Meeting Attended Borhan Saaio Transcultural Mental Health Officer, SA Meeting Attended

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APPENDIX 3: Identification and Evaluation of Innovative Models of Mental Health Service Delivery for NESB Communities: Project Summary. (text) IDENTIFICATION AND EVALUATION OF INNOVATIVE MODELS OF MENTAL HEALTH SERVICE DELIVERY FOR NESB COMMUNITIES The National Mental Health Policy has recognised that people from non-English speaking backgrounds have special needs which should be recognised in the planning and delivery of public mental health services. Evidence suggests that rates of mental disorder in NESB communities are generally higher than among the Australian-born community. There is also evidence that NESB people are admitted to hospital at lower rates than the Australian-born population, and that there is a lower rate of both voluntary and involuntary admissions for NESB people. There is also a lower rate of utilisation of community health services by NESB groups generally, a greater reliance on bilingual private psychiatrists and GPs for treatment, with less access to psychotherapy for poor English speakers and a greater reliance on medication. This project has been developed in the context of these issues. It is being conducted by the Australian Transcultural Mental Health Network by the Centre for Health Program Evaluation in the Department of Community Medicine at the University of Melbourne. To achieve the objectives of the project, five major tasks will be carried out. These are: 1. The development of criteria for the identification of innovative models of service delivery with the potential to improve the access which NESB communities have to mental health services. 2. Identification of and information collection on service delivery models. 3. Identification of innovative models. 4. Development and refinement of an evaluation framework. 5. In-depth examination and evaluation of three innovative models. The project is overseen by a Reference Group selected by the Centre for Health Program Evaluation. Internally the project is being supervised by a management team comprising staff members of CHPE. The written outcomes for the project will include several written reports at key points in the project, including the developed criteria, a list of existing services exemplifying different service delivery approaches and described in terms of the criteria, in-depth evaluations of three selected services, and a description of the development and implementation of the evaluation framework. At the completion of the project, a final report will be submitted accompanied by an ‘evaluation kit’ which will incorporate the developed criteria and the evaluation framework, appropriately presented for use by service providers, consumers and other interested people.

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APPENDIX 4: Centre for Health Program Evaluation, Letter Red: Case Studies (text)

Ms Shirley Wigan PO Box 5767 WEST END, QLD 4101. 20 November 1997 Dear Shirley Thank you for agreeing to help me carry out a Case Study at the West End Community Mental Health Centre. Following our conversation today, I’ll set out just what would be involved in the Study. The Case Study will comprise part of a project which I am currently conducting for the Australian Transcultural Mental Health Network, as part of the National Mental Health Strategy. I attach a description of the project. I have completed draft criteria and evaluation worksheets for use by community mental health centres, to assist them in providing access to their services for people of non-English speaking background (NESB). I attach copies of these. The purpose of the Case Studies in the project are: • to test thte usefulness of the criteria and evaluation sheets • to enrich the project’s grasp of the issues involved in providing access to mental health services for people of NESB • to apply the criteria and use the evaluation worksheets in a centre which is known to serve a high NESB population, and to be doing this well • to identify good service models for providing this access. In conducting the Case Study, I would like: to review the Centre’s relevant documentation relating to the provision of access to services to people of NESB. This may include policy documents, protocols, position descriptions, performance indicators, translated brochures describing the service, records of meetings with NESB community groups; • to meet with and observe at work the various teams in the Centre which work with people of NESB. This may include inpatient units, continuing care teams, crisis support teams, mobile support teams. I would envisage spending about half a day with each team.; • to attend case discussion meetings; • to meet with representatives of community groups concerned with the interests of carers and/or consumers of NESB; • to be informed about any outreach/educational programs undertaken by the Centre for people of NESB;

•

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•

to attend any other meetings suggested by management which would assist understanding of issues involved in providing service access to NESB people. I would like to complete the Case Study over a period of four days, preferably at a time between 1 December 1997 and 20 December 1997. If there is any material you could send me informing me about the Centre, and especially aobut how it provides services for its NESB population, this would be very helpful. Thank you very much for your help in this matter, and I look forward to hearing from you so that I can make the necessary arrangements.

Yours sincerely

Dr Helen Long Project Officer.

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8 December 1997

To whom it may concern, This is to attest that Dr Helen Long: is employed by the University of Melbourne; will be conducting a Case Study at the West End Community Mental Health Centre; will maintain confidentiality in the storage and usage of information obtained in the course of the Case Study; will send a copy of the draft of the Case Study Report to the Manager of the Centre for her information before incorporating it in a final report; and will participate in the business of the Centre at the invitation and permission of the Manager of the Centre.

Helen Long Project Officer. DEPARTMENT OF PUBLIC HEALTH AND COMMUNITY MEDICINE THE UNIVERSITY OF MELBOURNE, 243 GRATTAN STREET, CARLTON, VICTORIA 3063 AUSTRALIA TEL: +61 3 344 7276 FAX: +61 3 347 6136

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APPENDIX 5: NORTH WEST HEALTH CARE NETWORK POSITION DESCRIPTION FOR ETHNIC MENTAL HEALTH CONSULTANT (text) Title: Ethnic Mental Health Consultant

Classification:

PROG: Mental Health Programme

POSITION NO:

295930

NAME OF OCCUPANT: Yvonne Stolk

AWARD:

DATE OF REVIEW: (Job Description)

......................................................... Signature of Occupant Date:

................................................... Signature of Responsible Officer Date:

1. ROLE STATEMENT The role of the Ethnic Mental Health Consultatn is to contribute to the development of culturally sensitive practices within the Mental Health Program by implementing and evaluating the 1996 policy document Victoria’s Mental Health Service: Improving Services for People from a non-English Speaking Background. In undertaking this role, the Ethnic Mental Health Consultant will be a facilitator, educator and resource to all services in the Program. 2. REPORTING STATEMENT/WORKING RELATIONSHIP The Ethnic Mental Health Consultant would report to the . The Ethnic Mental Health Consultant would also work in close liaison with all levels of management and teams to support culturally sensitive practices. The Ethnic Mental Health Consultant would also work in close liaison with carer, consumer and community groups, the Victorian Transcultural Psychiatry Unit (VTPU) and the Ethnic Mental Health Consultants in other Victorian Health Care Networks. 3. OUTCOME STATEMENT AND TASKS 3.1 People from non-English speaking backgrounds (NESB) requiring mental health services will have equitable access to the full range of WHCN Mental Health Services. • In consultation with a project advisory committee comprising representatives of consumers, carers, staff and relevant groups, develop a strategy for ensuring equity in access to services.

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3.2 The Mental Health Program provides a comprehensive and equitable mental health service which meets the needs of people from NESB. Service gaps and areas requiring development in the field of culturally appropriate services and in particular language services are identified, documented and communicated to the Planning & Management Executive. Undertake to address the gaps as directed by the Planning and Management Executive. Assist AMHS managers and clinical staff develop and implement strategic plans, information systems, local procedures and practice guidelines which enhance culturally sensitive service delivery and meet with the standards of Victoria’s Mental Health Service: Improving Services for People from non-English Speaking Background Manage the development and implementation of strategies that promote links between the AMHS, local mainstream health service providers and ethno-specific services to improve mental health service outcomes for people from NESB. Develop, implement and provide progress reports on special purpose service development projects. In conjunction with the Victorian Transcultural Psychiatry Unit, contribute to the development of the role of bilingual case managers and provide supervision as required. 3.3 Staff needs in relation to education and training related to transcultural psychiatry, use of interpreters and cultural practices are identified and met. Undertake staff survey to identify gaps in skills and knowledge. Develop and implement/recommend options to meet staff needs. Provide as appropriate and coordinate cross-cultural in service training for staff. 3.4 Staff and Services are well resourced in information on culturally sensitive and appropriate aspects of health care and service delivery. Develop a strategy for the communication and distribution of resource information to staff, carers and consumers. Be available to staff, consumers and significant others for consultation on problems relating to culturally sensitive service delivery. Publicise results and outcomes of service evaluation activities at various levels within the service provision structure. Ensure dissemination of findings by publishing relevant reports and submitting articles for journal publication. 3.5 Cultural sensitivity in clinical practice and service delivery are managed within the quality framework. In consultation with the Program & Clinical Standards Committee, develop an Ethnic Health Audit involving information systems, consumer feedback and service operations. Participate in the implementation, audit and review of policies and procedures within the Mental Health program related to the provision of services. Undertake the evaluation of the efficacy of systems put in place to address the needs of people from NESB when requiring mental health services.

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3.6 Best practice models are used to improve services. Liaise with other Ethnic Units to keep abreast of changes and developments in Ethnic Health policies and practices. 4. KEY SELECTION CRITERIA MINIMUM REQUIREMENTS 4.1.0 Qualifications: A relevant qualification in any of the health disciplines of Occupational Therapy, Clinical Psychology, Social Work, Medicine or Nursing. 4.2.1 Other: 4.2.2 Wide experience in the mental health service provision system. 4.2.3 Experience in mental health services evaluation, statistical analysis and database management. 4.2.4 Good written and verbal communication skills including ability to communicate well with a wide range of people. 4.2.5 Ability to prepare reports/proposals outlining key issues. 4.2.6 Experience in training professionals in the area of health service provision. 4.2.7 Able to perform with limited direct supervision. 4.2.8 A current drivers license. 4.2.9 Ability to speak a relevant community language as well as English would be beneficial. 4.2.10 Ability to work with clients from a range of ethnic backgrounds.

5. ADDITIONAL INFORMATION 5.1 Travel would be required between sites and offices. 5.2 The incumbent will be required to consult across all services of the WHCN Mental Health Program. 6. TERMS AND CONDITIONS The Ethnic Mental Health Consultant will receive a salary package which will be negotiable and commensurate with experience. The appointment will be made for a period of 4 years.

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APPENDIX 6: North West Health Care Network - MidWest Area Mental Health Service: Position Description for Bilingual Case Manager. (text only) WESTERN HEALTH CARE NETWORK ADULT, CHILD AND ADOLESCENT MENTAL HEALTH PROGRAM MID WEST AREA MENTAL HEALTH SERVICE POSITION DESCRIPTION Title: Bilingual Case Manager Mid West Area Mental Health Service Contact for Applicants: Trish Altieri, Manager - Continuing Care Service Salary: As per award 1.0 INTRODUCTION The Mid West Area Mental Health Service forms part of the Western Health Care Network Adult, Child and Adolescent Mental Health Program. It provides a comprehensive range of psychiatric service to those who reside in the local government areas of Brimbank, Melton and part of Hume. The position of Bilingual Case Manager for the Mid West Continuing Care Service will undertake a range of duties, including intake/assessment and case management with a focus on one of Vietnamese, Macedonian or Croatian, clients of the service. They will also consult and liaise -with other agencies and community groups, especiallv those associated with the provision of services to clients from Vietnamese, Macedonian or Croatian backgrounds. In addition, the worker will be involved in focussed educational and community development activities for the service. The position is one of ten positions being established as part of the Bilingual Case Management Proiect -a joint initiative of the Western Health Care Network and the Victorian Transcultural Psychiatry Unit (VTPU). The VTPU has an ongoing role in the development, coordination and evaluation of the project. The position is based at Mid West Continuing Care Service, which has its main office in St. Albans, and will work with clients who are residents in the local govemment areas of Brimbank, Melton and partof Hume. The population has many interesting characteristics, including a diversity of cultural groups, socio-economic categories and environments, from inner-urban to semi-rural locations. Psychiatric services to residents residing in the Mid West Area include the Crisis Assessment and Treatment Team, the Mobile Support and Treatment Team, the Continuing Care Team, the In-patient Unit at Footscray Psychiatric Hospital. These services provide a range of acute, continuing care and rehabilitation service relating to psychiatric assessment and treatment Of severe psychiatric’ disorder. The effective delivery of high quality psychiatric services requires a high level of consultation and liaison between the component services of the Mid West Area Mental Health Service and with a wide range of community services and agencies.

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2.0 MAJOR RESPONSIBILITIES 2.1 Undertake complex casework with a range of clients, with a focus on clients from either a Vietnamese, Macedonian or Croatian background. 2.2 Provide joint case management, with other mental health staff from the Area Mental Health Service, to clients from a Vietnamese, Macedonian or Croatian background. 2.3 Provide consultation to professional staff from the Area Mental Health Service and the Western Health Care Network on matters related to the provision of services to clients from a Vietnamese, Macedonian or Croatian background. 2.4 As a member of the multidisciplinary team provide input to the development, implementation and review of services. 2.5 Consult and liaise with other mental health programs of the Western Health Care Network and other agencies and community groups, especially those associated with the provision of services to clients from Vietnamese, Macedonian or Croatian backgrounds. 2.6 Contribute to the training and supervision of staff and students as appropriate. 2.7 Assist in the administration of functions related to the provision of professional services. 2.8 Participate in evaluation activities as required. 3.0 QUALIFICATIONS 3.1 Preferred qualifications include: + Nurse: Registered as a Nurse With the Nurses Board of Victoria in Division I with approved Post Graduate Qualifications in Psychiatric Nursing or registered as a Psychiatric Nurse with the Nurses Board of Victoria in Division 3; + Occupational Therapist: Approved Degree from a recognised school of Occupational Therapy or other qualifications approved for membership of the Australian Association of Occupational Therapy (Vic); + Social Worker: Approved degree in Social Work, or other qualifications approved for membership of the Australian Association of Social Workers; + Psychologist: Approved degree with a major in psychology and to be registered under the provisions of the Psychological Practices Act 1965. Approved postgraduate qualification in Clinical Psychology and membership of the College of Clinical Psychologists (Australian Psychological Society) 3.2 Applicants with qualifications and experience in a related area may be considered. 4.0 REPORTING RELATIONSHIPS 4.1 The Bilingual Case Manager is responsible to the Manager, Mid West Continuing Care Service.

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5. 5.0 MINIMUM REQUIREMENTS 5.1 Post graduate experience in social work, psychology, psychiatric nursing or occupational therapy in a psychiatric service within a community-based setting and a capacity to deal appropriately with crisis situations. 5.2 Fluency in either Vietnamese, Macedonian or Croatian, and a knowledge of Vietnamese, Macedonian or Croatian culture. 5.3 Sound knowledge of the Mental Health Act, and other relevant legislation, policy and strategic directions in psychiatric services. 5.4 Sound communication and interpersonal skills, and experience in consultation and community development activities. 5.5 Demonstrated ability to-provide a full range of professional services and participate in program implementation and review. 5.6 Ability to function independently, and as part of a multi-disciplinary team. 5.7 A commitment to on-going professional development 5.8 Current Victorian driver’s licence is required. 6.0 OTHER HELPFUL SKILLS, KNOWLEDGE AND EXPERIENCE 6.1 Ability to provide input to the policy and program development functions of the service. 6.2 Ability to work with clients from a range of ethnic backgrounds.

7.0 OTHER RELEVANT INFORMATION 7.1 Out of hours work may be required. 7.2 Occupant may be required to travel between or work from any of the Mid West offices. 7.3 The tasks, roles and responsibilities of the position will be reviewed after a period of six months.

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APPENDIX 7 North West Health Care Network Mental Health Program: Policy and Procedure for Culturally Sensitive Practice (Draft) WESTERN HEALTHCARE NETWORK Policy & Procedure Manual Continuum of Care Reference Number: Date of Review: February, 1997 Next Review Date: June, 1997 Page I of 10 Policy CULTURALLY SENSITIVE PRACTICE PRINCIPLE Mental health services will provide services to people of non-English speaking background (NESB), which are accessible, equitable and acceptable to people of diverse cultural backgrounds. Services which are culturally relevant demonstrate an awareness and respect for the cultural framework of members of ethnic groups. The terms Ethnic and of non-English speaking background are used interchangeably, include refugees, and are used to refer to Victorian residents who: • were born overseas in a non-English speaking country (i.e. not in New Zealand, UK, Republic of Ireland, Canada, USA or South Africa) • are Australian-bom with at least one parent born-in a non-English speaking country; or • are Australian-born and have strong affiliation’s to a cultural and linguistic heritage that is not Anglo-Celtic. (Report of the Ministerial Taskforce on Ethnic Health, 1991). The Human Services publication, Victoria s Mental Health Service: Improving Services or People from a non-English-Speaking Background (1996) provides the guiding principles and standards to be followed by services. Policies and procedures for the Western Health Care Network Mental Health Program are set out below under the following categories: * Designated Responsibility Within Services. * Access * Language Services * Assessment and Treatment * Staff Training and Development * Information Provision * Staff Recruitment 120

Page 2 of 10 Policy CULTURALLY SENSITIVE PRACTICE DESIGNATED RESPONSIBILITY WITHIN SERVICES STATEMENT Administrative structures will be established in mental health services to allocate responsibility for the continuing responsiveness of services to ethnic communities. OUTCOMES • Each mental health programme will appoint an interested senior staff member to coordinate activities relating to services to ethnic communities. • The nominated staff member will liaise with other ethnic issues co-ordinators in the service and will report regularly to the relevant Area Manager/Director and Local Executive. • The Ethnic Mental Health Consultant (EMHC) of the Western Health Care Network (WHCN) and the Victorian Transcultural Psychiatry Unit (VTPU) are available for consultation. Page 3 of 10 Policy CULTURALLY SENSITIVE PRACTICE ACCESS STATEMENT Mental health services will endeavour to remove- obstacles to access for members of ethnic communities which are created through a lack of information on mental health and services, perceived stigma, unfamiliar service structure and the language barrier. OUTCOMES • Services will develop consultative procedures with ethnic community groups, clients/patients and carers to identify appropriate strategies to reduce access barriers. • Services, will undertake community education projects in relevant languages to inform ethnic communities about mental health issues, psychiatric services, rights, and the availability of language services (see next Section). • Community education information may be disseminated through ethnic radio and newspapers, multilingual printed information circulated to bilingual general practitioners, community health centres and ethno-specific agencies. Radio is especially suitable for NESB people not literate in their own language.

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• Services will endeavour to create a welcoming environment through multilingual signs and notices, ethnic newspapers and pictures relevant to local ethnic communities.

Page 4 of 10 Policy CULTURALLY SENSITIVE PRACTICE LANGUAGE SERVICES STATEMENT Effective communication is fundamental to the provision of high quality mental health services. People of non-English speaking background and those who are hearing-impaired have the right to professional language services where this is required to facilitate communication. Language services will be provided only by appropriately accredited interpreters or bilingual clinical staff, except in an emergency. Written information made available to clients/patients by Services will also be available in translated form in major community languages. OUTCOMES • Multilingual signs advertising language services will be prominently displayed in reception areas in all services and programs..- TIS (Translating and Interpreter Service) “Help Cards” will also be available at these locations. • At intake or admission to a mental health service, all clients/patients with a language preference other than English, or those who are hearing impaired, and their carers: * Will be informed of their right to professional language services; * This information will be conveyed in the consumer’s preferred language either verbally, in translated written form, by audio-tape or through a telephone interpreting service; * If the information is provided in translated written form, it is necessary to determine whether the client/patient is literate in her/his own language; * A client/patient has the right to refuse language services. In this event, staff have a right to language services for their own purposes to meet their responsibility to ensure that accurate communication occurs. * Members of the patient/client’s family will not be asked to act as interpreters except where an interpreter is not available in an emergency. In this event, it is necessary to engage professional language services as soon as possible to clarify that accurate communication occurred.

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Page 5 of 10 Policy CULTURALLY SENSITIVE PRACTICE LANGUAGE SERVICES (Cont d) *Bilingual clinical staff have a clinical role and are not to be asked to act solely as interpreters. The need for language services may be established by: * The client/patient’s request for language services; or * Assessment by the service provider that language services are required to facilitate communication. This assessment should take into account that communications regarding psychiatric conditions require a higher level of English comprehension and expression than everyday communications. * Respect will be shown for gender, privacy and political considerations expressed by consumers when interpreters or bilingual staff are engaged. * An Interpreter Alert sticker, with the appropriate language recorded, will be placed on the medical record if the need for language services has been established. An accredited interpreter or bilingual clinical staff member is to be available during key processes throughout the client/patient care episode to ensure maintenance of clients/patients’ legal rights and clients/patients’ right to communicate in their preferred language. Language services will be available to facilitate all psychiatric services provided to clients/patients, not only medical services. The key processes include: * Intake and assessment * Medical assessment and review * Explanation of diagnosis, treatment and, especially, medication and its sideeffects * Obtaining informed consent for procedures * Allied health programs and interventions * Explaining reasons for admission to an inpatient unit to patients and carers * Ward orientation and explanation of patients’ rights * In a self-harm situation when a patient/client is very disturbed * Resolving disputes with other patients on the ward * Discharge planning and on discharge

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Page 6 of 10 Policy CULTURALLY SENSITIVE PRACTICE LANGUAGE SERVICES (Cont d) * To inform the client/patient’s family or carers * Inpatients are to be provided with language services at least once every second day to facilitate informal conversation in their own language and minimise social isolation * Each occasion of service facilitated by language services is to be documented in the clients/patient’s medical record. * Reasons for not using professional language services must be documented to cover legal liability. Each mental health service will have clearly identified procedures for the booking of interpreters and new staff will be introduced to these procedures during orientation. Each mental health service will provide a three-way telephone for the effective use of telephone interpreter services and all staff will be trained in its use. All facilities will make provision for the on-going education of clinical staff in the competencies of working with an interpreter to ensure maintenance of professional standards. Translations: * Before translating written information into community languages, staff will ascertain whether an existing translation exists of similar material. The Australian Transcultural Mental Health Network maintains a directory of translated documents and may be consulted for this purpose. * Key language groups in the catchment area will be identified to determine into which languages material is to be translated. * Written translated material will be translated by accredited translators and will be backtranslated to ensure accuracy of the translation. * Pilot testing will be conducted with relevant consumers before the information is printed.

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Page 7 of 10 Policy CULTURALLY SENSITIVE PRACTICE ASSESSMENT AND TREATMENT STATEMENT Psychiatric assessment, treatment and case management will be conducted demonstrating an awareness and respect for the clients/patients’ cultural framework. Clinical staff members must be aware that their own and their clients’ conceptions of mental illness are influenced by their cultural perspectives. Past cultural experiences can affect a person’s willingness to seek and continue with treatment. Service providers will show respect for the central role the family or other carers may play in seeking treatment and in supporting the maintenance of treatment. OUTCOMES • Psychiatric assessment and treatment is conducted with an understanding by the service provider that people of non-English speaking background may have culturally-specific beliefs and expectations regarding the nature and treatment of mental illness. • An endeavour will be made to develop a shared understanding between the service provider and the client/patient about mental illness and the possible treatments. • Psychiatric assessments are conducted with an understanding of cross-cultural differences in the manifestations of symptoms. • Service providers will demonstrate an understanding that people of non-English speaking background may be fearful of psychiatric and other government services because of past cultural experiences. • Bicultural/bilingual clinical staff will be employed to foster the confidence of ethnic communities in the services provided. • With the agreement of the client/patient, clinical staff will explain the diagnosis to carers and seek their co-operation in the treatment plan. • Service providers will refer people of non-English background to bilingual clinical staff outside the mental health service if appropriate or if the person requests this. The Victorian Transcultural Psychiatry Unit maintains a directory of bilingual/bicultural clinicians.

⇑ Services will develop partnerships with bilingual general practitioners, general health and ethno-specific services to provide assessment and treatment services in a non-threatening environment.

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Page 8 of 10 Policy CULTURALLY SENSITIVE PRACTICE STAFF TRAINING AND DEVELOPMENT STATEMENT Clinical staff will encouraged to undertake training in cultural issues in mental health to enable them to develop the knowledge and skills necessary to plan and provide relevant services in culturally diverse settings. Attention to transcultural issues in mental health will become integral to all mental health training programs. ograms. Services of the Western Health Care Network (WHCN) will make provision for relevant training. OUTCOMES • The Victorian Transcultural Psychiatry Unit and the Ethnic Mental Health Consultant of the WHCN will advertise, provide and advise on transcultural training activities for clinical staff. • All staff training activities will include reference to transcultural issues where relevant. • Applications for study leave to undertake the Graduate Diploma in Mental Health Sciences (Transcultural Mental Health) and other approved transcultural mental health seminars, conferences, Workshops and courses will be viewed favourably, within the context of current study leave guidelines. • Applications for study leave from multilingual staff who wish to undertake language training to achieve clinical proficiency in a language other than English, will be viewed favourably, within the context of current study leave guidelines. • Issues which may arise from the cultural background of clients will be acknowledged in clinical supervision.

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Page 9 of 10 Policy CULTURALLY SENSITIVE PRACTICE INFORMATION PROVISION STATEMENT Staff and Services are well resourced in information on the distribution of ethnic communities in their catchment area and on culturally sensitive practice. OUTCOMES • The Victorian Transcultural Psychiatry Unit (VTPU) and the Ethnic Mental Health Consultant (EMHC) of the WHCN will provide or co-ordinate provision of census data and information on psychiatric service use relating to local ethnic communities. • Services will develop, in co-ordination with the VTPU and the EMHC, readily accessible transcultural resource files which include information on the demographic and cultural background of ethnic communities in their catchment area, policy and standards. documents, cultural issues committees and membership, and other relevant information. • Orientation of new staff will include introduction to policies and procedures relating to service provision to people of non-English speaking background. • The VTPU and the EMHC will be available for consultation on issues relating to culturally sensitive service delivery. • Staff and Services will receive information on transcultural issues through the VTPU publication Connections and the WHCN Bulletin.

Page l0 of 10 Policy CULTURALLY SENSITIVE PRACTICE STAFF RECRUITMENT STATEMENT Services will endeavour to reflect in their staff profile the ethnic composition of their catchment area. OUTCOMES Advertisements for clinical and non-clinical staff positions will indicate that the ability to speak a community language is a desired skill. Services will designate a certain number of positions as bicultural/bilingual clinical positions.

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REFERENCES American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, 4' Edition. Washington, DC.: American Psychiatric Association. Health Department Victoria (1992) Working with people rom non-English speaking backgrounds: Guidelines for Health Agencies. Melbourne. Human Services (1996) Victoria s Mental Health Service: Improving Services for People from a non-EnglishSpeaking Background. Melbourne. Mezzich, J.E., Kleinman, A., M.D., Fabrega, H., Jr., & Parron, D.L. (1996) Culture & Psychiatric Diagnosis. Washington, DC: American Psychiatric Press. Minas, I.H., Lambert, TJR., Kostov, S. & Boranga, G. (1996) Mental Health Services for NESB Immigrants: Transforming Policy into Practice. Report of the Ministerial Taskforce on Ethnic Health (1991) Health Services and Ethnic Communities: an Agenda for Change. Melbourne: Health Department Victoria. Stolk, Y. (1996) Access to Psychiatric Services by People of non-English Speaking Background in the Western Metropolitan Region of Melbourne, Volumes I & 2. Melboume: Victorian Transcultural Psychiatry Unit. Approved By Kerrie Cross Chief Of Clinical Programs 26 February 1997

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APP 8: NORTH WEST HEALTH CARE NETWORK MENTAL HEALTH PROGRAMME: MID WEST AMHS STRATEGIC PLAN OBJECTIVE

TASKS

RESPONSIBILITY OF

* To extend the existing Inpatient Education Debbie McBryde (Unit Programme into an Area based Education Programme. Manager) Monica Lynagh * To address the education needs of NESB (Snr Social Worker) families & carers. * Promoting Family Sensitive Practice through Improve the quality of the inservice, education and formation of a services we provide to our NESB committee with representatives from all clients. progamme. * Implement Model Of Bilingual Case Trish Alteri (CCT Manager) Management. Trish Alteri (CCT Mger) * Develop strategies for encouraging the Robyn Garlick (Coordinator employment of Bilingual staff (Clinical & Non ongoing CSP)) Clinical) to the Mid West AMHS * Audit clinical forms to ensure that cultural & Program Mgers language specific issues can be readily identified. * Service audit by ADEC. Scott McBurnie(CATT * Carer Support Programs targeting NESB Mger) population. le PALS Project - Encourage Marian Grimw ald (0.T) Regional Office to fund. * Set up a regular forum to meet with local Trish Saunders(A.M) Trish agencies who have particular interests in NESB Saunders (A.M) issues * All programs will include as a part of their Program Managers and regular inservice sessions, education and Divisional Seniors. information relating to culturally sensitive practice. All programs will develop signage to meet the needs or NESB clients All programs will have service infprmation available in other languages. The Area will develop a multilingual education package for clients and carers. Ensure that all family members have access to education and information regarding mental illness and available services.

DATE March 1997 ongoing

December 1996 February 1997 .

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December 1996

April 1997

February 1997

June 1997

OBJECTIVE • Actively involve local General Practitioners in the care of clientsis who experience serious mental illness. •Ongoing consultation and liaison.with other community stakeholder ie Consumers, Carcrs, NGO’s,a nd other govt agencies.

TASKS * Develop a model for shared care specific to the needs of clients fit the Mid West AMHS.

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The Mid West Consultative and Advisory Group has been established. Need to ensure Mid West AMHS is an equal stakeholder and that the group is active in * improving services provided to people who suffer serious mental illness. * Establish linkage agreetnews with all relevant stakeholders. • Ensure that all clinical and non * A model of supervision will be forniulated clinical staff have access to after discussion with a sta.ff & Programme professional supcrvision. Managers. * The existing orientation process for most • All staff must participate in a staff is very good, however, the process formal orientation process, of orientation needs to be standardized which includes orientation to all and ratified. programmes within the Mid Wcst * Identify the generic and specialist AMHS as well as orientation to requirements for orientation and Western Hospital and Disability incorporate litem fit an orientation Support Services. manual. * Work with oflicr AMI IS widiin the • Information sys(cins should be Network to develop an comprehensive user friendly and responsive to Information System / Data base. the needs of all programmes. * Liaison and linkages widi GP’s, police, ambulance, CHC. • Provide an cffective efficient * Develop a visible profile fit Sunbury. and responsive service to the * Analyze service patterns and respond to Sunbury Area. findings. *I nvestigate the development of a small satellite service.

RESPONSIBILITY OF

DATE

Dr.1111singhe (Director of Clinical Services) Dr Tout Wissenger (Stir Medical Officer CCI)

March 9197

Trish Saunders (Area Manager).Jill Collin (CCU

‘January 1997

R Garlick, Monica Lynagh , Glenda Pedwell , June Blenkhorn

June 1997

Robyn Garlick (Clinical Nurse Consultant) Monica Lynagh (Snr Soc , Worker) Glenda Pedwell (Snr O.T)June Blenkhorn (Stir Psychologist

Oct 1995 ongoing

T Saunders (AM)SMc Buride Ongoing (CAn’Mger)

Ongoing

Scott Me Burnie (CATT Manager)Simon Brentnelll (MST Manager) Trish Altirl (CCT Manager)

March 97

OBJECTIVE

TASKS

RESPONSIBILITY OF

DATE

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Effect an increase in the level of Disability Support services to the Mid West AMHS

* Review with Regional Office the provision of Disability Support Services available to clients who Manager) reside in the Mid West.

Trish Saunders (Area Manager) All staff

Ongoing

Establish closer linkages with Tertiary Institutions in order to: • Enable the institutions to respond to our educational & professional needs. • Promote mental health as a potential career path. • Provide input / give feedback on course content • Utilize the expertise of senior clinicians.

Encourage NGO’s to expand services to the Mid West

Seniors

April 1997

Lobby the Regional Office to provide fund for PAL Pograill * Regular promotional visits to talk to students about Mental Health. * Meet with Academic Stiff to formilly Iiiisc rcgardhig courses and. * Promote tertiary courses and encourage participation. * Formalize relationships. Investigate Network position on joint Academic/Clinical positions

OBJECTIVE Provide an effective, efficient and responsive service to all areas of the catchment within the guidelines of the Department of Human Services and Western Health Care Network.

Provide a safe environment for consumers and staff.

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Participate in ongoing consultation and liaison with other Area programmes and non-government service providers in the catchment.

TASKS Recruit appropriately qualified bi-lingual staff wherever possible

RESPONSIBILITY OF Trish Altieri (Manager) & Senior staff.

DATE Ongoing

Ensure information is provided in client and All staff carer’s preferred language and in a manner that facilitatees understanding.

Ongoing

Monitor triage function and analyse referral patterns and outcomes.

Trish Altieri (Manager)

Ongoing

Monitor patterns of service utilisation and service provision.

Trish Altieri (Manager)

Ongoing

Monitor clinical services through regular review of clients’ Individual Service Plans and regular clinical supervision.

Trish Altieri (Manager) and senior clinical staff

Ongoing

Trish Altieri (Manager) and sernior staff

February 1997 & Ongoing

Trish Altieri (Manager) and senior clinicians

Ongoing

Utilise Divisional Performance Appraisal system with all staff (when developed).

Trish Altieri (Manager) and divisional senior clinicians

Ongoing

Review and develop emergency policies and procedures.

Trish Altieri (Manager) all staff Ongoing

Develop formal mechanisms for evaluation of clinical care and client outcomes. Develop a comprehensive orientation programme for new CCT staff.

Ensure all staff are aware of polices and procedures through training. Develop linkage agreements with relevant services.

staff development committee

Ongoing

Trish Altieri (Manager)

Ongoing

Appendix 9 North West Health Care Network Mental Health Program: Mid West In-Patient Unit Strategic Plan WESTERN HEALTHCARE NETWORK MENTAL HEALTH PROGRAM: MID WEST lN-PATIENT UNIT

TASKS

RESPONSIBILITY OF

DATE

Ensure that family members/ carers have access to education and information regarding mental illness, treatment modalities and available services.

* Family/Carer monthly education nights, providing verbal and printed information. * Promote positive milieu sensitive to family/carers education/inforniation needs. * Distribute survey to ensure understanding and information provided is relevant to family/carers needs.

Debbie McBryde (Unit Manager) Dr. Hati Chopra. (Consultant Psychiatrist)

Ongoing

AlI patients and staff to participate in a Community Meeting to ensure a forum is available for open communication.

* Meetings scheduled on weekdays. * Patients informed of meetings as part of orientation when admitted to ward. * New staff familiarized with duties in regards to Community Meetings. * Terms of Reference have been developed. * Promote ongoing commitment to Community Meetings. * Shift Managers to allocate staff to Meetings. * Meetings minuted and actioned.

Debbie McBryde (Unit Manager) Shift Managers Stephen Buttigieg ,

Ongoing

Non English Speaking patients to have access toInterpreting Services.

* Promote sensitive practice through inservice and education. * Provide education on accessing Interpreters and interviewing techniques.

Debbie McBryde (Unit Interpreting services. Manager) Robyn Garlick (Clinical Nurse Consultant) Representative Mental Health Interpreting Service

January 1997 ongoing

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OBJECTIVE

APPENDIX 10: North West Health Care Network Mental Health Program: Mid West MST Plan

OBJECTIVE

TASKS

RESPONSIBILITY OF

DATE

135

Manager & Staff committee February 1997 Ensure provision of adequate As in Area Mental Health Service, develop a and relevant information to all mutilingual information package to be given to ongoing). registered clients and their all clients or the M.S.T. service and their carcrs, about the service. carers. Manager & Staff committee February 997 On an ongoing basis continue to Development of client/carer satisfaction assess -client and carer survey, followed by implementation on a biReview February satisfaction levels with the annual basis 1998. services provided to them. Develop protocols with the non-government Manager & Staff committee ongoing (as services Continue to develop clinical PDS services in the Mid West catchment. are developed.) relationships and protocols with Continue to develop a model of shared care Manager, MST Staff & on going consultant psychiatrist / the non government Psychiatric for M.S.T. clients. medical officers. Disability Support Services. Manager & Staff Continue to develop clinical Ensure appropriate use of interpreters on going Manager & Staff committee February 1997 & involvement of local G.P’s and Develop links with NESB non government psychiatrists in the clinical care community basedsupport services. ongoing of M.S.T. clients. Multi-lingual information is to be provided to Manager & Staff committee February 1997 Improve services to NESB NESB clients and carers. clients. Recruit appropriately qualified bi-lingual staff Manager and Western on going Hospital Personnel Dept. of clinical assessment tools wherever possible. regarding living skills and mental Development of M.S.T. base line assessment Manager & MST staff October 1996 state for all M.S.T. clients tool for living skills and mental state. Review October Manager Provide an effective, efficient Monitor and analyse referral patterns and 1997 and responsive service to the outcomes. ongoing Manager areas of the catchment within Monitor patterns of service utilisation and ongoing the guidelines of the Western service provision. Manager HealthCare Network and the Individual Service Plans and regular clinical ongoing Department of Human Services. supervision. Develop formal mechanisms for evaluation of Manager & staff.commitee. February 1997 & on Participate in ongoing clinical care and client outcomes. Manager & staff consultation and liaison with Develop a comprehensive orientation November 1996 other program area and non programme for new MST staff. Western Hospital - Div of government service providers in Utilise Divisional Performance Appraisal 1996/97 . . the catchment System with all MST staff (when developed) Psychiatry Executive Manager 1996 ongoing Develop linkage agreements with relevant services

APPENDIX 11

North West Health Care Network Mental Health Program; Mid West CATT Strategic Plan

OBJECTIVE Ensure provision of adequate and relevant Information to all registered clients and their carers, about the agency and the services it offers.

To assess client and carer satisfaction levels with the services provided to them.

136 To assess referring agencies’ satisfaction with contact with the agency (including GPs and private psychiatrists).

Involve local GPs in the care of persons with severe mental illness. Improve services to NESB clients.

TASKS

RESPONSIBILITY OF

DATE

Develop multilingual information package to be given to all entrants to the service and their carers.

Trish Altieri (Manager) Staff committee

February 1997 & ongoing

Develop checklist for case managers’ use to ensure relevant information is passed on to clients and their carers.

Trish Altieri (Manager)

February 1997 & ongoing

Conduct initlal client and carer satisfaction survey and implement identified strategies.

Trish Altieri (Manager) & all staff

February 1997 & ongoing

Conduct annual client and carer satisfaction survey.

Trish Altieri (Manager) & all staff

Annually

Conduct initial satisfaction survey which examines the agency’s response to the contact, and referrer’s level of satisfaction with the contact.

Trish Altieri (Manager) and all staff

February 1997

Conduct annual satisfaction survey.

Trish Altieri (Manager) and all staff

Annually

Develop a model of shared care for CCT clients.

Dr T. Weisinger and committee

Ongoing

Ensure appropriate use of interpreters

All staff

Ongoing

OBJECTIVE

TASKS

Ensure provision of adequate and relevant information to & all registered clients and their caters, about the agency and the services it offers.

As an Area Mental Health Service, develop multi-lingual information package to be given to all entrants to the service and their carers. Develop checklist for clinicians use to ensure relevant inforrnation is passed on to clients and their carers. Conduct initial client and carer sntisfaction survey and implement identified strategies. Conduct annual client and carer satisfaction survey.

Scott McBurnie (-Manager) Staff Committee

February 1997 & ongoing.

Scott McBurnie (Manager) & all staff.

In existence.& ongoing

Conduct initial satisfaction survey which examines the agency’s response to the contact, and referrer’s level of satisfaction with the contact. Conduct annual satisfaction survey.

Scott McBurnie & all the clinicians.

Bi-annually.

Scott McBuniie (Manager) & all staff

February 1997

Dr Simms and Scott McBurnie (Manager)

Ongoing

Ensure appropriate use of interpreters. All staff Recruit appropriately qualified bi-lingual Scott McBurnie (Manager) and staff wherever possible. clinicians. Ensure information is provided in client and All staff. carer’s preffered language and in a manner that facilitates understanding.

Ongoing Ongoing

Continue to assess client and carer satisfaction levels with the services provided to them.

137

To assess referring agencies’ satisfaction with contact with the agency (including G.P.’s and private psychiatrists).

Continue to involve local G.P.’s in Continue to develop a model of shared care for CATT clients the care of persons with severe mental illness .

Improve services to NESB clients.

RESPONSIBILITY OF

DATE

Scott McBurnie (Manager) & all staff.

Ongoing

OBJECTIVE Provide an effective, efficient and responsive service to all areas of the catchment within the guidelines of Department of Human Services and Western Health Care Network.

138

Provide a safe environment for consumers and staff

Participate in ongoing consultation and liaison with other Area programmes and nongovernment service providers in the catchment.

TASKS

RESPONSIBILITY OF

DATE

Monitor intake function and analyse referral patterns and outcomes. Monitor patterns of service utilisation and service provision. Monitor clinical services through regular review of clients’ Individual Service Plan and regular clinical supervision. Develop formal mechanisms for evaluation of clinical care and client outcomes. Develop a comprehensive orientation programme for new CATT staff. Utilise Divisional Performance Appraisal system with all staff (when developed).

Scott McBurnie (Manager)

Ongoing

Scott McBurnie (Manager)

Ongoing

Scott McBurnie (Manager) and senior clinicians.

Ongoing

Scott McBurnie (Manager) and clinicians. Scott McBurnie (Manager) and clinicians. Scott McBurnie (Manager) and clinicians.

February 1997 and Ongoing Ongoing

Review and develop emergency policies and procedures. Ensure all staff are aware of policies and procedures through training. Develop linkage agreements with relevant services.

Scott McBurnie (Manager) and all staff Scott McBurnie (Manager) and all staff Scott McBurnie (Manager)

Ongoing

Ongoing Ongoing

Appendix 12:

North West Health Care Network Mental Health Program: St Albans CCU Strategic Plan

OBJECTIVE #1. To provide a client-centred multi-disciplinary service aimed at collaborative approach with consumers who have a serious menful illness and challenging behaviours.

TASKS

RESPONSIBILITY OF

DATE

139

* To implement an effective casePeter Kelly, Manager management system for all clients through the appointment of an appropriate case manager. * Identify the individual’s needs develop All staff on Multidisciplinary and implement an Individual Service Plan in Team. negotiation with the consumer, their carers and the multi-disciplinary team, in recognition of different views and life experiences.

Ongoing

* On admission to the CCU residents will be given a list of local GP’s and provided with the opportunity to choose a GP of their choice.

Case Manager, as appointed.-

Ongoing

* Establish a regular review of the ISP to evaluate and monitor a client’s progress.

All staff on Multidisciplinary Team.

JAn”97 & Ongoing

* Establish a response foruin at critical periods in consumer’s lives when such a need arises. A ‘response forurn’ integrates network service providers (eg. CAT-r, MST, FPH, ‘ CCT) and other relevant bodies (eg. families) for the purpose of achieving best service outcomes. * Establish a support group for carers to residents of the CCU. * Improve service delivery in relation to different cultural, spiritual and/or gender needs.

Peter Kelly, Manager Client’s nominated Case Manager & Multidisciplinary Team.

Ongoing

Peter Kelly, Manager. Jill Collins, Social Worker. Morna Harper. PS02.

Jan ’97 & Ongoing

Ongoing

OBJECTIVE

TASKS

RESPONSIBILITY OF

DATE

* Establish processes in the ISP’s so that consumer/carers choice and preferences are the major guide for decision making about services provided for them. * Establish a consumer/carer group as a vehicle by which their choices and preferences become (lie major guide for the decision making about services provided lor them. Provide a mechanism whereby cons umers/carers are given information about lodging complaints. * Provide a service mechanism whereby consumers are given information in a timely and sensitive way. * Provide an resource folder to each consumer containing relevant information on mental illness and the range of support groups available.

Peter Kelly A/Unit Manager Ongoing All nominated Case Managers.

#3. To explore the most flexible and creative response in addressing client’s needs and wishes through the recognition of the client’s strengths and their right to take acceptable risks.

* Develop a risk assessment framework that guides behaviour management plans. * Explore an ‘alternative management plan’ within the multi-disciplinary team and relevant agencies in ‘response forurns’. * Negotiate a co-operative - approach with consumers and carers for the implementation of alternative management plan’ process. * Provide information, documentation and evaluation of outcomes to all parties involved.

Peter Kelly, A/Unit Manager

140

#2. To ensure empowerment of consumers by maximising their autonomy in decision-making about management of their mental illness, its Iife style consequences and their use of services providing better outcomes.

Multidisciplinary Team

Ongoing

OBJECTIVE

#4. To facilitate consumer’s involvement in the delivery and planning ofservices.

141 #5. Ongoing consultution and liaison with other community stake holders holders. i.e. consumers, carers, NGO’s and other government agencies.

#6. The CCU to provide an orientation programme relevant to all staff’s level of need. #7. Ensure that all clinical and non clinical staff to have access professional supervision and staff development

TASKS

RESPONSIBILITY OF

DATE

* Ensure team support for all staff members implementing ‘alternative management plans’ by encouraging staff participation in ‘response forums’ and I.S.P. reviews. * Provide debriefing for all people involved in critical incidents. * Ensure all staff receive regular and appropriate supervision. Peter Kelly, A/Unit Manager Jan 97 and * Establish a CCU consumer-carer advisory Ongoing Jill Collins, Social W orker. group that is involved in service delivery Morna Harper, PS02 planning. * Explore proposed infrastructure changes that impact on resident’s quality of life through regular brainstorming sessions with consumers, Multidisciplinary Team carers and staff. * Establish a communication network with line Peter Kelly, A/Unit Manger Ongoing management to negotiate best outcomes for proposed infrastructure changes. * Establish linkage agreements with all other stake * Establish an orientation program that is appropriate to each discipline. * Develop a checklist and feedback sheet to ensure satisfactory completion of an orientation programme

Peter Kelly, A/Unit Manager Ongoing Jill Collins, Social Worker. Peter Kelly, A/Unit Manager

’ Peter Kelly, A/U Manager * A model of supervision will be formulated after discussion with a staff and program managers. * An Inservice Program to be further developed Nominated Divisional Seniors. of an ongoing nature.

Ongoing

ADDENDUM TO APPENDIX

Case Study Documents 1. Mid West Community Mental Health Service. An Overview n.d. Demographics n.d. Western Health Care Network Mental Health Program Policy and Procedures Manual. February 1997 • Area Policy on Culturally Sensitive Practice. n.d. • Program Policy on Culturally Sensitive Practice • Mid West Area Mental Health Strategic Plan • Bilingual Service Directories -Vietnamese -Slavic and Macedonian -Croatian -Maltese -Private Mental Health Practitioners -List of Bilingual GP’s • Working with the Vietnamese Community. Thuy Diuh 1996, South West AMHS • The Mid West AMHS Non-English Speaking Background Carers’ Project n.d. • The Multicultural PALS Project n.d. • Proposal for a Pilot Bilingual Case Management Program for the Western Metropolitan Region, n.d. • Ethnic Issues Group: Terms of Reference, n.d. • Papinacoulaeou and Fitch, Evaluation of the Area Mental Health Services Response to the Needs of People from NESB: Mid West AMHS, 1997. • • •

2. Rockingham Kwinana Psychiatric Service-Western Australia • • • • • •

ANZ Bank. Mental Health Service Achievement Awards 1997: Proposal Operational/Business Plan 1997 Australian Bureau of Statistics, Census, 1991 Rockingham Kwinana Psychiatric Services Policy and Procedures Manual, 1996 Language Service in Health Care: Policy Guidelines, 1994 Your Rights Under the Mental Health Act 1996, 1997. Health

142

Department of Western Australia • Non-English Speaking Background Project 1997 • The Multicultural Nursing Role -a Description n.d. • Cross-cultural Psychiatric Nursing Assessment, 1996

3. Princess Alexandra Hospital and District Mental Health Service, Queensland (PAH&DMHS) • • • • • • • • • •

PAH and DMHS n.d. PAH and DM Health Service Structure-Adult Mental Health n.d. Minimum Service Standards for Mental Health Services in Queensland-Queensland Mental Health 1993 Procedures for Persons of Non-English Speaking Background. Queensland Transcultural Mental Health Centre (QTMHC) 1997 Resource Kit for Persons of non-English Speaking Background QTMHC 1997 Draft Policy Statement for PAH and DMHS Acute Care n.d. Evaluation of the Bilingual Mental Health Program n.d. Mental Health Interpreters n.d. Ethnic Mental Health Program-Queensland Association for Mental Health n.d. Queensland Program of Assistance to Survivors of Torture and Trauma Inc n.d.

143

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