Editorial

On disadvantage

Graham Martin OAM
Professor of Child and Adolescent Psychiatry, Discipline of Psychiatry, University of Queensland, St Lucia QLD

PP: 081 - 084

Article Text

As a clinician I am often confronted by disadvantage. Mary is a good example; a 14 year old from a rural background who gets admitted to our Adolescent Unit repeatedly when she overdoses, or following an episode of cutting. She is the oldest of five children to three of mother's partners, her own father hanging himself in the bathroom and being found by Mary when she was five years old. Since then, for one reason and another, she has had a difficult relationship with her mother and eventually was placed in care at about 11, which led to a cycle of running away, living on the streets, committing various minor acts of vandalism and theft, being picked up by the police and returned to a new foster placement. Over recent months, the behaviours have escalated with episodes of prostitution, a number of people being physically abused and cars being stolen for a joy ride.

Despite being of above average intelligence, and very verbal (if poorly educated), Mary is difficult to engage toward making any sort of supportive and therapeutic relationship. She does not trust easily, is often difficult, provocative and rude, and you just think you are making progress when some small thing goes wrong and it is all blamed on you. Of course with a highly traumatised background, and a variable emotional state, she has been labelled with all sorts of diagnoses and personality problems, the latest being that ragbag of psychiatry emerging 'borderline personality disorder'. But of course the real problems are in the trajectory of her life, the lack of secure attachment, the recurrent traumas, and the need for a young person to attempt prematurely to survive on their own.

I state the problem as survival, because I have a certain admiration for Mary. She is a survivor, even though at times she does place herself in the way of serious potential dangers. She has an admirable determination to remain autonomous (despite the fact that this often blocks her from accepting help and support), along with a set of attitudes, knowledge and strengths that allow her not just to live on the street, but actually thrive on the streets. Many of her life choices are uncomfortable to hear about, and may have long-term adverse consequences. You can wish that there were other ways to survive, that she would just accept one supportive foster carer, that she could find just one trustworthy life guide to help her get back on track. But for the time being you have to just hope she lives long enough to find some new ways; if she does she will be one tough woman.

As many of you would recognise, at this point in the game, even taking a strengths-based perspective, it is very hard to intervene. And you look back through the course of her life and can see so many times earlier on when intervention may have been possible. But, then the cards were stacked against her very early on. Poverty, living in a rural community, poor family education, a predominantly single parent family, repeated family traumas, multiple episodes of abuse, frequent changes of school, and then four years of being in and out of the welfare system.

This brings me to a very interesting new report from the National Centre for Social and Economic Modelling (NATSEM) based at University of Canberra. Poverty and Disadvantage Among Australian Children: A Spatial Perspective, presented at the 29th General Conference of the International Association for Research in Income and Wealth, Joensuu, Finland (20-26 August 2006). What Ann Harding (2006) and her group have done is to take 2001 Australian census microdata (Australian Bureau of Statistics) focussed on well-being and disadvantage from the child's perspective. They developed a composite index of child social exclusion at the small area level and then analysed the regional differences for risk - with some stunning results. In developing the index for social exclusion they drew on international research that identifies four dimensions of social exclusion - consumption (the capacity to purchase), production (labour force status and occupation), involvement in local and national politics and organisations (social capital and educational attainment), and social interaction and family support. The actual measures that NATSEM used are Income, Family Type, Education in family, Occupation in family, Housing tenure, Parents speaking English at home, Labour force status of parents, Personal computer usage, Motor vehicle ownership - and together these contribute about 52% of the variance of the social exclusion index. The point that Harding and her group make is that this gives a much more comprehensive understanding of disadvantage that just poverty on its own.

What emerges is a rather stunning map of child social exclusion in Australia - clearly evident in some suburbs of all of our cities (page 17 of the report). Overall, as expected perhaps, capital cities do better than the remainder of states and territories (that is other towns, and rural and remote areas), and some states and territories can be shown to be doing very well compared with others. So, small percentages of the child population appear in the overall bottom social exclusion (high disadvantage) decile for ACT (0%), Victoria (2.1%), New South Wales (5.3%), and Western Australia (5.7%) compared with high percentages for South Australia (17.6%), Queensland (25.1%) and Tasmania (36.3%). Conversely, looking at the highest decile (low disadvantage) there is a continuation of the story. High percentages appear for ACT (24.3%), NSW (13.3%) and Victoria (11.0%), and lower percentages for South Australia (5.8%), WA (6.4%), Queensland (6.7%) and Tasmania (0%). In summary, ACT, Victoria and NSW contribute disproportionately to the highest decile (low disadvantage); South Australia, Queensland and Tasmania contribute disproportionately to the lowest decile (high disadvantage). Of interest in these latter 3 states, although less than 3 per cent of all Australian children live in Tasmania, 9.2 per cent of all those children are in the bottom child social exclusion decile. Similarly while 20 per cent of all Australian children aged 0 to 15 live in Queensland, almost 49 per cent of all those children are in the group at greatest disadvantage.

Where does this lead us? Well, if we return to Mary's story, it is unlikely that she has a genetic loading for mental illness as such. She is very much the victim of social disadvantage. If we want to change the story, that is reduce the numbers of people with similar struggles to those of Mary, it will be too little too late and too difficult if we only consider what is necessary in terms of sufficiently resourced mental health services. We must begin to think strategically as to where to place resources for family life, early childhood programs and education, and translate the excellent NATSEM report into relevant action. Within this it is clear that South Australia, Queensland and Tasmania have considerable room for improvement for those 0-15 year olds at major disadvantage and likely to swell the referrals to mental health services in due course. Once again we have evidence that shouts out to us the need for the promotion of mental health, and relevant early intervention. In moving to action, we must continue to focus on resilience building and connectedness (Oh, those old things) and have the courage of our convictions in promoting what we know is needed to enhance attachment, parenting skills and supports for family life. In addition, we must have the resources and collaborative partnerships to be able to intervene much earlier at strategic points along the early life pathway. Two things I have not addressed which are discussed further in the report are the obvious fact that large numbers of our indigenous peoples live in what are areas of highest social exclusion. And also the intriguing fact that having English not spoken at home (one of the items in the NATSEM composite index) may contribute to disadvantage.

This, of course, is relevant to the topic of this issue of the journal. My point is that we are disrespectful of anyone outside a particular frame, and like many of the papers in this issue, I am calling for change at a wide level to move toward true multiculturalism.

We owe a considerable debt of gratitude to Nicholas Procter from the University of South Australia for acting as Guest Editor for this multicultural mental health special issue of AeJAMH; he has worked tirelessly to draw together the papers, assisting our editor Anne O'Hanlon to produce what is an immensely important issue. In his editorial, Nicholas reminds us forcefully of the complexities of immigration to Australia, the problems in our detention system which so often lead to adverse outcomes, and the difficulties faced by our mental health systems in becoming truly culturally competent. The messages are strong in that we must learn to recognise and value diversity. More than that, both as individuals and as parts of systems, we would do well to learn respect for what those from different backgrounds may teach us about life and how to live it.

There are two other guest editorials. Meg Griffiths from Multicultural Mental Health Australia, comments on mainstreaming, and the complexities of building capacity and partnerships to meet the policy rhetoric. MMHA provides information and training to both multicultural consumers and carers on the one hand, and mainstream professionals on the other, often working in partnership with the wide range of government and non-government organisations in the field.

Leslie Swartz from South Africa, in discussing the move toward multilingualism at Stellenbosch University, describes some of the complexities and deep suspicions that may arise in native speakers when academics begin to reach out and learn languages such as Xhosa. Even with experience, it is still easy for misunderstandings to occur. Goodwill alone, he notes, is unlikely to be accepted simply for what it is. Some lessons for multiculturally sensitive work in Australia are clear.

The first of our papers for this issue is reproduced with permission from Medicine Today. Jill Benson, a general practitioner, drawing on her work with both migrants and aboriginal people, describes in detail the implications of three key issues necessary for cultural sensitivity - an appreciation of our own ethnocentrism, the consumer or carer's need for health literacy, and transcultural perceptions of illness. Having admitted that it impossible for any one of us to grasp the nuances of all cultures, Jill describes a culturally aware approach that has its roots in narrative, solution focussed, and 'one down' approaches, where the clinician begins any interview by seeing the clients as the experts in what they know and want.

In a fascinating account of Somali women living in New Zealand, Pauline Guerin from the University of South Australia, and her colleagues, describe how weddings, parties and ritual can contribute to mental wellbeing, and therefore be of importance in protecting migrants from trauma based illnesses. The authors argue that professionals taking an active part in supporting such events, as well as adequately supporting refugees more generally in their resettlement, is an investment for everyone.

Melinda Redmond and her colleagues from Curtin University describe an important piece of research focused on the understanding of depression across cultures. Using an open-ended questionnaire approach with 11 international experts, they derive insights from a three-phase consensus Delphi approach. From a very careful and thoughtful piece of work it emerges that there are clearly aspects of unipolar depression which are truly transcultural. In contrast there are aspects that are culture related, and it would appear that we still have a long way to go before we understand these culture-derived aspects, and the complexity of making meaningful comparisons of depression across cultures.

Rita Prasad-Ildes and Elvia Ramirez from the Queensland Transcultural Mental Health Centre describe a consultation process with a broad cross-section of culturally and linguistically diverse consumers, reporting what was said to be of importance to them from a mental illness prevention approach. Not surprisingly, an improvement in the understanding of mental illness amongst family, friends and colleagues was of major importance, and this related to stigma and its possible reduction. However, in this remarkably rich read, an enormous number of other issues are discussed and reported in the words of particular individuals from various ethnic groups.

In counterpoint, Rosanna Rooney from Curtin University, and colleagues, examine perceptions of carers from culturally and linguistically diverse (CALD) backgrounds regarding their conceptualisations of mental illness, stress and support, stigma, and pathways to seeking help. Again, perhaps, only some of the issues that emerge are surprising, in that they are similar to those that might be complained of by other Australians - lack of involvement in the treatment process, insufficient communication from health professionals, lack of understanding about mental illness, lack of support, and so on. However, in addition, there were other more specific obstacles echoing prior research - language barriers, a lack of knowledge about service availability, and the incongruence between their culture and that of mainstream culture.

Pauline McLoughlin from the University of Adelaide returns to one of the themes raised by Nicholas Procter's editorial: Australia's inhumane approach to asylum seekers in our immigration detention centres. The author argues that effective mental health promotion efforts are likely to be bound to the setting, in itself a profoundly negative barrier to emotional wellbeing. Detained asylum seekers, marginalised and excluded, then have to suffer the prolonged experience of what is often a punitive system. In a carefully argued and well referenced paper, McLoughlin concludes, in part, that the efforts of externally-acting advocates and community groups represent the only force as yet significantly capable of overcoming the obstacles. There is clearly much work to be done at multiple levels.

In the final paper of what is a rich overview of current transcultural thinking and activity, Ruth DeSouza from the Auckland University of Technology explores the efforts being made for improvement in the mental health of Asian people in New Zealand, in a context where one in five New Zealanders are migrants. A major issue explored is that migrants to New Zealand may be caught up in the current dissonance between the colonial ideal of a homogenous society, and the desire of Maori people for recognition as people of the land, with specific rights. The author ends a very instructive paper on an optimistic note - that while there are still challenges in the operationalisation of how mental health services ensure they are responsive in both policy and practice for 'migrants, refugees and Asians', progress is being made.

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