1. The Multicultural Mental Health Project Project Worker, Patrycja Toczek Australian Polish Community Services Patricia.Toczek@mh.org.au Patricia.Toczek@mh.org.au

2. Aims of the presentation  To provide information about the Multicultural Mental Health Project (MMHP)  To provide an overview of the issues faced by ethnic communities in particular the communities selected for the purpose of the project (Arabic speaking, Cambodian, Chinese, Macedonian and Polish)  To facilitate discussion about issues faced by Culturally and Linguistically Diverse (CALD) communities in context of mental health practice

3. Multicultural Mental Health Project background  The project was funded by the William Buckland Foundation and Coles Group Community Fund to promote mental health awareness amongst five ethnic communities in Victoria:  Polish – Australian Polish Community Services  Arabic – Victorian Arabic Social Services  Cambodian – Cambodian Community Welfare Centre  Chinese – Chinese Health Foundation  Macedonian – Macedonian Community Welfare Association

4.  Research  Community development  Resource development  Capacity building Multicultural Mental Health Project Aims

5. Mental Health and CALD communities ABS data (2005) indicates that the number of people of non English speaking backgrounds (NESC) diagnosed with mental and behavioral problems is proportional to those born in Australia (ABS 2005); however people of CALD background are often characterized by higher levels of psychosocial distress (ABS 2005); a language barrier is often reported to cause emotional and psychological distress in critical situations (Sozomenou et al, 2000)

6. Mental Health and CALD communities: service utilisation As noted in the “Access to mental health services in Victoria” (Stolk et al, 2008):  NESC compromise 20% of the Victorian population whereas NESC mental health service users compromises 13% of community clients and 15% of inpatients  A higher percentage of NESC clients than Australian-born community clients were admitted to acute inpatient units with a higher percentage of severe mental disorders (e.g. psychosis, schizophrenia) which resulted in longer admissions  Treated prevalence for the majority of ethnic communities was significantly lower than for Australian-born population

7. Issues faced by CALD communities As noted in VicHealth report (2007) there is evidence from a number of Australian studies, which suggests that the culturally and linguistically diverse communities of low-socio economic backgrounds remain disadvantaged:  in everyday contexts (Dunn, Forrst et al 2004: in VicHealth, 2007),  their access to housing (Allbrook 2001; Moriarty, Babacan & Hollinsworth 2006; DHS 2000: in VicHealth 2007),  health-care (Grove & Zwi 2006 in: Vichealth 2007),  employment (Colic – Peisker & Tilbury 2005 in: Vichealth 2007) and  education (Dunn, Forrset et al 2005 in: Vichealth 2007).  CALD communities are also at a higher risk of developing a range of health problems (Paradies 2006; Williams et al 2003 in: Vichealth 2007)

8.  Stage 1: Needs assessment /Consultations  Stage 2: Working group preparation to community sessions  Stage 3: Partnership Building  Stage 4: Community education sessions  Stage 5: Evaluation Multicultural Mental Health Project - Methodology

9. Profile of the ethnic communities: Arabic speaking community  Arabic speaking community as the most varied community in Victoria made up of 41,000 people of different ethnic backgrounds including: Lebanon, Egypt, Iraq, Syria and some newly emerging African communities (e.g. Sudanese) of different religious denominations (predominantly Christian and Muslim)  Young profile  MMHP focused on women and young people identified as most vulnerable populations in the community with high prevalence of depression, anxiety and post traumatic stress disorder (PTSD)

10.  Mental health as a damaging illness “Mental health is like cancer, people do not easily discuss the diagnosis. They fear the stigmatization not only to themselves but to the other members of their family”  Mental health as a weakness seen in negative terms and evidenced through the stigma significantly impacting upon the whole family “Some young people won’t even take their medication as needed because they are afraid of what their peers will think about them. They don’t want to be labeled as ‘crazy’”. Arabic speaking community: Perception of mental illness

11.  Mental health not viewed as a serious problem unless manifested with physical symptoms ‘Mental health is not really taken seriously in the community. Unless it is affecting them physically they won’t seek help. Depression is not seen as a mental health issue, people think that it has no affect on the person physically therefore it must not be that bad’  Stigmatization of the mental health illness and mental health professionals “Everyone seems to know each others’ business in the community, people seem to be more sensitive towards mental health and find it difficult to even use certain terminology such as the word counseling; people get defensive” Arabic speaking community: Perception of mental illness

12. Profile of the ethnic communities: Cambodian community in Victoria  Community of refugees arrived in Australia subsequent to the Pol Pot regime  Collective traumatic war time experience resulted in high prevalence of PTSD in the Cambodian community  Traditional family composition with children and family members caring for the elderly  Disability regarded as shameful and a strong cultural stigma is attached to mental illness in particular

13.  Limited Understanding about mental illness and the concept of recovery “Not normal thinking or working of the brain in the person.” “It is a problem of many thoughts in your head. These many thoughts in your head will cause the lack of sleep, being upset, really sad.”  Mental illness often viewed as a taboo associated with bad spirits, bad karma, witchcraft or upsetting ancestors “Cambodians see that problems of the brain like this have to do with the spirit of the ancestors being upset with someone in the family. The ancestor makes the person upset. That’s why it comes to your family.”  Mental illness denied and feared due to its attribution to severe emotional disturbance and possession by malicious spirits “Many Cambodians believe that the spirit of the land or water has taken over the person because the spirit is upset.” “It is a bad Karma of the person who has got this illness.” Cambodian community: Perception of mental illness

14.  Attitudes towards mental illness different comparing to other illnesses such as heart disease, diabetes, asthma etc “ If they go to see the doctor about their illnesses such as heart disease, diabetes, asthma etc., the doctor will prescribe them the medications to take and so on. They then follow the doctor’s orders and their illnesses will be improve and be in control. However, if they go to see the doctor about their mental illness, the doctor will prescribe them the medication to take to help them to sleep all the time. These tablets make the person worse because they don’t do things at all anymore. This is worse.”  Ambivalent feelings towards sufferers of mental illness and their families “You feel ashamed to let anyone know your family has this problem. Because you worry not only for that person who has the problem, but it can mean it is not easy for the other siblings or relatives to get married as well. People would think that if you marry to that person or that person’s siblings or relatives it is in their breed. So stay away from that breed.” Cambodian community: Perception of mental illness

15. Profile of the ethnic communities: Chinese community  Large and diversified community  Impact of traditional Chinese Medicine on the way mental health is viewed as balance within the body  The Chinese-born community regards disability as shameful, and a strong cultural stigma is attached to mental illness  Disability is viewed as a punishment for wrongdoing by the person or the family in a previous life; the families affected may believe that they are paying a debt that is owed  Services sought if issues are regarded as “acute” or “very serious”

16.  The link between mental health condition and harm/violence  The mentally ill are differentiated in the community  Lack of knowledge, understanding and awareness towards mental health issues Chinese speaking community: Perception of mental illness

17. Profile of the ethnic communities: Macedonian community in Victoria  Macedonian community as ageing community  Traditional views on the family values and responsibility for looking after elders  Seeking services seen as shameful and as a failure to fulfil ones duty to the family  Mental illness and disability stigmatised and not openly discussed within the community

18.  Mental health viewed as a burden and something that brings shame to the family; individuals are often to blame for having a mental illness  Fear of being judged by others in the community which often leads to denial about the illness  Stigma attached to the topic of mental health exacerbated by a lack of education, limited knowledge and access to information and services  Varied understanding of the condition in different age groups and a lack of understanding about mental health preventative measures Macedonian community: Perception of mental illness

19.  Polish community an ageing community with two major waves of migration occurring after the 2WW (60, 000) and during the Solidarity Movement in 1980’s (20, 000)  Depression, isolation and schizophrenia are identified as major issues impinging on the mental and emotional wellbeing of the Polish community  Elements of PTSD amongst the ageing – especially those with dementia- related conditions  Strong stigma attached to mental health exacerbated by fear of what others will think  Strength, independence and ability to work out one’s own problem viewed as important values  Family, religion and social networks viewed as strong protective factors Mental Health and CALD communities Polish community

20.  Varied understanding of the mental illness “People suffering from schizophrenia are sometimes quiet and isolated from the people. The person thinks that he/she is not liked by the others and is shutting down from the outside world. Slowly one can turn into a violent psychotic person e.g. rapist. However, sometimes a person suffering from mental illness can be very intelligent and has strong preference towards living in one’s own world”.  Depression described as illness of “dullness and isolation” not viewed as mental illness and of high prevalence in the community  Mental health as a disability viewed as a weakness “People seeing a person suffering from a mental illness made him/her look more retarded than he/she really was”. Polish community: Perception of mental illness

21.  Social isolation exacerbating the mental health condition in the community  Impact of war on individual experiences and life chances “The 2WW survivors believed that their life would be much happier and better should they not have gone through the experience of war. The unfulfilled youth dreams made them disillusioned about their future choices: “A person remains silent and angry; constantly seeks someone that would provide one with answers, provide some support”.  Contributing factors: carers’ stress, alcohol, death of a close relative/friend Mental Health and CALD communities Polish community

22. Testimony I suffered from an anxiety attack. It was terrible and I felt like dying. It happened all of sudden one night. I felt something was strangling me and I thought I was not going to survive. I developed a feeling of panic and fear, which continued for a while. Despite the fact that I was involved in the life of my community and have many friends I felt that I had nobody to share these feelings with. I felt lonely and isolated. My life was worthless and meaningless. At the end these depressive thoughts turned into experiences of breathlessness and I started experiencing breathing difficulties, which turned into high blood pressure. I ended up in a hospital. It was explained to me there that there was a link between the panic attacks and the high blood pressure, which provided me with a greater understanding of what was really happening in my life. On discharge from the hospital, I was not referred to any mental health specialist. It took me a while to find a mental health professional, who spoke my language. Although I have been living in Australia for over 20 years my English knowledge is limited and I feel much more at ease communicating in my native tongue. It made the task of finding mental health professionals more difficult as there are not many of them around. I was lucky; a friend of mine helped me to find a psychologist who spoke my language and who she had utilized in the past. The psychologist provided bulk billing services and agreed to see me for six sessions. Despite the long distance to travel, which meant long hours using public transport, the sessions brought great improvement to my general wellbeing.

23.  Limited understanding of the concept of mental health  Mental health viewed as a weakness  Attitudes towards mental illness different compared to other illnesses such as heart disease, diabetes, asthma etc  Negative feelings of shame and embarrassment experienced by people suffering from mental health conditions and their carers  Stigmatization of the mental health illness and mental health professionals Mental Health and CALD communities: common themes:

24.  Reluctance to identify mental health issues for what they are often results in denial  Reluctance to seek assistance  Exacerbated isolation  Carers failing to seek support and assistance  Lack of awareness about available service system Popular CALD attitudes towards mental illness

25. Barriers to services  Stigma attached to the topic of mental health or differing explanatory model of mental illness  Lack of education, limited knowledge and access to information and services  Lack of understanding of the mental health system  Language barrier  Lack of culturally and linguistically suitable services and resources

26. Sources of support  Individual resources  Family members/relatives  Friends  Religious representatives/prayer  GPs  Social groups  Active way of living  Ethno-specific services

27. Perception of mental health services & mental health professionals  Cambodian: “These mental health services do not understand how to treat us Cambodians. Like they not understand our traditional beliefs.” “These mental health services do not understand how to treat us Cambodians. Like they not understand our traditional beliefs.” “I know one family, the wife of my nephew. She was not well mentally. She received treatment from mental services here but not help her. So they took her to Cambodia to see if they can find traditional Cambodian healer. She is still there and it helps her.” “We know someone ill like this and when they get to hospital and see doctors they got better but never the same as before. Like it changed the person, they look not well, not talk to you fully. They are 50% not 100% any more. Hard for the family.”  “As noted by a Polish speaking counselor participating in one of the sessions, there is a strong belief in the Polish community that psychologists manipulate people’s brain and leave them changed for life to the degree when they are not able to make their own independent decisions. As a result, people leave counseling sessions transformed into almost involuntarily patients. Psychologists are therefore not viewed as practitioners promoting wellbeing but rather as charlatans, of which people should be aware”.

28.  Achievements: - raised community awareness about available services with a focus on health promotion and early intervention utilizing formats appropriate to NESC - development of culturally and linguistically appropriate interventions in collaboration with mainstream service providers - enhanced the model of positive health and primary interventions by addressing those at increased risk incl. survivors of trauma and torture, young people, carers  Potential outcomes: - increased access to the service system prior to crisis intervention - increased usage of funded counselling services to diminish the risk of conditions worsening - increased support and understanding within communities, thus reducing isolation and stresses related to mental health issues - increased prevention of the onset of serious mental health issues through increased awareness of risk factors and preventative measures Multicultural Mental Health Project -Discussion

29.  Lack of accurate epidemiological data reflecting the prevalence of mental health conditions in CALD communities  Limited time and resources  Lack of ongoing funding  Limited evaluation of the project due to a number of factors, including: participants’ reluctance to provide written feedback as a result of stigma, limited level of education and issues of confidentiality Multicultural Mental Health Project - Limitations

30. Multicultural Mental Health Project – Recommendations  More focus on prevention and early intervention in culturally and linguistically appropriate format  Provision of ongoing long-term funding to ethnic communities  More collaborative approach to mental health promotion between main stream and ethno-specific sector  More targeted approach by government and funding bodies in responding to mental illness  More epidemiological studies of ethnic communities

31. Thank You

32. Contact details:  Australian Polish Community Services 77 Droop St, Footscray 3011 Tel (03) 9689 9170 Fax (03) 9687 7446 Email: www.apcs.org.auwww.apcs.org.au  Cambodian Community Welfare Centre Inc. 16-20 Silver Grove, Nanawading, Vic 3131 Ph/Fax: (03) 9877 9732 Email: ccwcinc@optusnet.com.auccwcinc@optusnet.com.au  Chinese Health Foundation of Australia Suite 12, 27 Bank Street, Town Hall Hub, Box Hill Town Hall, Box Hill, 3128. Te: (03) 9285 4812 Fax: (03) 9285 4813 Email: chinesehealth@optusnet.com.auchinesehealth@optusnet.com.au  Macedonian Community Welfare (MCWA) Shop 19 Princess St., St. Albans Ph: 9310 75566 Email: www.mcwa.org.auwww.mcwa.org.au  Victorian Arabic Social Services (VASS) 178 Dallas Drive, Broadmeadows Ph: 9309 0055 Email:mail@vass.org.aumail@vass.org.au

33. Literature Andary, L., Stolk, Y. & Klimidis, S., 2003, Assessing Mental Health Across Cultures, Queensland: Australian Academic Press Australian Bureau of Statistics, 2005, Mental Health and Wellbeing: Profile of Adults, Australia, Canberra 2005 Bakshi, L. Rooney, R. & O’Neil, K., 1999, Reducing Stigma about Mental Health in Transcultural Settings: A Guide, Melbourne: the Australian Transcultural Mental Health Network Department of Human Services (Eastern Region) & Migrant Information Centre (MIC) ( Eastern Melbourne), 2004, Cultural and Religious Profiles to Assist in Providing Culturally Sensitive Care and Effective Communication, Melbourne: Migrant Information Centre (Eastern Melbourne) Sozomenou, A., Mitchell, P., Fitzgerald, M., Malak, A.,E. & Silove, D., 2000, Mental Health Consumer Participation in a Culturally Diverse Society, Sydney: Australian Transcultural Mental Health Network

34. Literature Stolk, Y., Minas, H & Klimidis, S., 2008, Access to mental health services in Victoria. A focus on ethnic communities, Melbourne: Victorian Transcultural Psychiatry Unit Tefera, A., 2007, The Struggles for Resettlement, Multicultural Mental Health Australia, last cited on 21.10.2007 Tilbury, S.E., Wright, B., Rooney, R. & Jayasuriya, P., Cultural Awareness Tool. Understanding Cultural Diversity in Mental Health VicHealth 2007, More than tolerance: Embracing diversity for health: Discrimination affecting migrant and refugee communities in Victoria, its health consequences, community attitudes and solutions – A summary report, Melbourne: Victorian Health Promotion Foundation