Guest Editorial

'They first killed his heart (then) he took his own life': Reaching out, connecting and responding as key enablers for mental health service provision to multicultural Australia

Nicholas G Procter
Professor and Chair: Mental Health Nursing, School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Adelaide SA

PP: 085 - 089

Keywords

multicultural mental health, immigration detention, culturally and linguistically diverse backgrounds, mental health services, cultural competence

Article Text

After a damning Senate Report into Australia's mental health system, there is finally a sense across Australia that something is actually happening to help make a difference to people with a mental illness and their carers. The $1.9 billion allocated by the Federal Government for a new National Action Plan on Mental Health (Council of Australian Governments: COAG, 2006) over the next 5 years is a welcome commitment. The funding will lift mental health's share of the total health expenditure in Australia from 7% to 8%, but is still well short of the 12% called for by the Mental Health Council of Australia.

But I do wonder if the needs of people from diverse cultural and linguistic backgrounds will be better met through this action plan.

Earlier this year the Commonwealth Ombudsman released a report into the circumstances of the immigration detention of a Australian citizen with a mental illness. Originally from Vietnam, the report reveals how 'Mr T' who suffers from schizophrenia was detained by officers of the Department of Immigration and Multicultural Affairs (DIMA) as a suspected unlawful non-citizen on three occasions between 1999 and 2003. On one of those occasions he was detained in Villawood Detention Centre for a period of eight months. Immigration officials, police and mental health professional shortcomings led to a monumental failure of duty of care for Mr T who, due to his mental illness, his homelessness and lack of an effective personal social support structure, his poor English language skills and his ethnic background, could not possibly advocate for himself.

The mistakes of the Australian immigration detention system don't come as a surprise. It is a system unregulated by public scrutiny and where mental health care has been heavily criticised by people who fundamentally know what they are talking about. The detention environment is injurious to mental health and the people who are inside it will express their injury in ways that are in keeping with their culture. We don't often hear about the nature and scope of mental injury unless there is something that makes the story newsworthy. After all, television news is driven by visuals. If there is 'no vision' then the local television news will often be reluctant to run an item.

But there are some exceptions to this. For example, through the mainstream media we got to know a great deal about Cornelia Rau and the way she was treated because, as many commentators have pointed out, Cornelia is 'one of us'. And so 'it happened to one of us'. A permanent resident in Australia, Ms Rau was considered to be having behavioural difficulties and other problems because the symptoms of a medical condition were not properly recognised or more importantly accepted within the immigration detention environment. This prevented her from receiving the combined human rights and antipsychotic intervention she so desperately needed.

The unlawful detention of Ms Rau led to the Palmer Inquiry. The inquiry concluded that urgent reform was needed to remove a strong culture of denial and self justification within DIMA and that a lack of training of clinicians (inadequate mental health assessment, lack of seeking out collateral information, lack of cultural competency in the assessment) contributed to an overall inadequacy of mental health care provided at the Baxter Detention Centre.

If the recommendations of the Palmer Inquiry are to be properly implanted they must be underpinned by a dose of humanity not really evidenced by the Australian Federal Government. The Federal Government must, as a considered response, end the callous portrayal of refugees and asylum seekers (as Zygmunt Bauman, 2004, would call them) as 'stateless, placeless, functionless, illegals'.

This notion of wasted lives brings me to the title of this editorial. It comes from the death of an asylum seeker - not in Australia but in Scotland. On Friday 18 May 2004, Zekria Ghulm Salem Mohammed completed suicide in Glasgow just days after he was told by the British Home Office that his claims for asylum had been rejected and he must return to Afghanistan. Electronic and print media reports surrounding the death indicate that, after exhausting all legal attempts to stay in Britain, he was told that he would have to leave his flat, and his £38-per-week allowance for food and other essentials was stopped. Informal, non-government supports failed to arrive and he was 'too proud to beg and scavenge for food in bins'. Forbidden to work or study, starving, ashamed and broken, he felt there was no hope left. He smashed a glass panel above a door, looped a rope around it and hanged himself. As one of his close friends, who found his body, told Scottish television, 'They first killed his heart and drove him to such a condition that he took his own life'. This classic statement and the circumstances of his distress is the interpretive beginning of the practice formulations contained in this editorial.

In Australia too there have been suicides and attempted suicides by people released from Immigration Detention Centres. Let me tell you briefly about the story of Abass (not his real name).

Abass is a refugee on a Temporary Protection Visa who was interviewed just days after he attempted to hang himself from live powerlines. With the assistance of an interpreter the interview took place sitting with legs crossed on the lounge room floor of his rented room in a hostel. Questions were asked in an indirect rather than direct way as this was the interviewer's preferred mode to help the interviewee avoid feeling shame or become reticent in openly discussing their situation.

The interview began with a brief introduction of who the interviewer was and relied upon the key words 'I am not here to hurt you, I am here to listen to your story'.

Abass began speaking, appearing quite nervous (picking the carpet with his fingers, smoking cigarettes back-to-back, limited eye contact, shaking, and he had a soft almost inaudible voice); however, as the conversation developed he seemed more relaxed and disclosed the following key points:

He arrived in the region four months ago to work at the local chicken farm. He spoke no English on arrival to Australia and learned basic language skills from some of the people he had been living with at various times since being released from Immigration Detention into the community.

In the 7 to 14 days leading up to the suicide attempt he had been missing his family (terribly), fearful of the outcome of his Permanent Protection Visa application, living in limbo, and this had kept him awake at night. He would go to bed at night around 11.00 pm or midnight, initially falling asleep and then awaking at around 1.00 am. He described his grief, his loss, his shame, his difficulty in concentration, and suicidal thinking. The interviewer noticed between 8 to 12 burn marks on his right arm. When asked about these Abass described them as self inflicted using a lit cigarette. He said he had mostly done this at night, felt no pain - nor any discomfort or distraction from the smell of his burning flesh. He also described how he would sometimes walk the streets at night prior to burning his body. He talked of feeling as if 'all people hated him' ... 'all his Australian and non-Australian (Afghan) friends did not like him here'. 'Nobody wants us here ... it's all politics,' he said.

On the day he attempted to kill himself he had been with some friends but described feeling 'out of his body'. He left his friends at around 2.00 pm and sat alone in his car in a car-park for about two hours. After this time he began to drive home. During the journey to his house he described how a cat had run across the road. He told of swerving to miss it and drove into a tree damaging his car. Despite this his car was still drivable and he made it home.

Once at home he sat on the lounge room floor and at that point decided to kill himself. He took some electrical wire (possibly an extension cord) from behind his stereo player and went to an electricity pole a few streets away from his home. He climbed the pole, wrapped the extension cord around the telegraph wires and around his neck and was swinging and struggling in the air (freefall) when a car carrying adult male occupants was driving past. The occupants of the car spotted him and two of the men grabbed his legs to release the pressure around his neck and another two climbed the telegraph pole to bring him down. From there he was taken to the local hospital. After remaining in hospital for 24 hours he was discharged back into the community. He then asked the interviewer, 'Why do you want to help me? What is in it for you?' He felt no sense of belonging to the local community, and could not remember the faces of his own children. He is trying to trust others. He wants to believe that his life is worth living.

Much of the mental heath and wellbeing of people like Abass is dependent upon a favourable outcome in his application to the Federal Government for a Permanent Protection Visa and the reunification with his family.

Also important will be his acceptance by health and human service workers and the culturally competent way they respond. And it is to this context that I will now turn my attention.

In June this year the National Health and Medical Research Council endorsed Cultural Competency in Health: A Guide for Policy, Partnerships and Participation (NHMRC, 2006). The report argues that to effectively promote positive mental health and social environments to a diverse nation, a national approach is required. This should target all levels of government and promote better services through the creation of networks, planning and strategic direction. Below are some key messages from the report.

The health sector must form partnerships with ethnic communities, specialist migrant, refugee, torture and trauma services, and together develop culturally appropriate health promotion and health service delivery that is consistent and sustainable. The aim should be to transform health policy, planning and delivery, so it is suitable for a culturally diverse Australia, increasing cultural competency at all levels of the system, partnering with the multicultural sector in planning, implementing and evaluating health promotion strategies, and reducing health inequalities in the short and long term.

For people from culturally and linguistically diverse backgrounds, special care will need to be taken. Australia is one of the most culturally diverse societies in the world. Everyday in Australia there are more than 240 languages spoken (and that does not include the languages of Aboriginal Australia). So it is time to make sensitive revisions of clinical assessment process ensuring that they are open to cultural difference.

For some this will mean finding new ways to free their vision on what is culture and what it means at an individual level.

'Culture' gives people meaning and context to the way they communicate thinking, action and events. 'Culture' also allows people to make assumptions about social and emotional life, illness and death and how they should be understood within a particular context or setting.

When individuals from one culture find themselves living in a different cultural context there may be differences in the way that they communicate idioms of distress and suffering. In mental health emergencies (for example) it is important to look beyond taken-for-granted assumptions regarding the way that symptoms of mental distress are communicated and the personal meaning that people from culturally and linguistically diverse cultures give to diagnosis, treatments and outcomes. For this reason people from culturally and linguistically diverse backgrounds remain a population group requiring special attention to their mental health status. This approach is the foundation of the Australian Health Ministers' Framework for the Implementation of the National Mental Health Plan 2003-2008 in Multicultural Australia (Commonwealth of Australia, 2004).

The challenges of a diverse population - of developing a culturally inclusive mental health assessment remain. Here are some cultural and language considerations relevant to the assessment in mental (ill)health:

• It is not uncommon for stress to increase the likelihood that a person from a culturally and linguistically diverse culture may revert to their language of origin.
• If a person speaks a language other than English at home the use of a bilingual health worker or an accredited interpreter service must be considered.
• Be aware that a prior relationship between the patient and an interpreter can be a problem in small ethnic groups - in particular new and emerging communities - where there tend to be fewer accredited interpreters.
• Cultural differences can result in markedly variable mental health presentations. Cultural differences can influence the way in which symptoms are presented, what is considered a good outcome, acceptance of prescription medication and help seeking behaviour more generally.

So the presentation and explanation of mental distress and suffering will vary according to social and cultural influences. Although conditions, such as depression, might have similar physical symptoms across cultural groups, emotional symptoms, such as social withdrawal, guilt and self-blame, are not universal. This suggests that the expression of mental suffering and distress needs to move beyond a strict Western ontology to include the role of sociocultural and other moderating factors.

Similarly, steps need to be taken in order to avoid the traps that can occur in making assumptions about cultural influences. Any attempt to raise levels of cultural awareness runs the risk of stereotyping those from different ethnic groups. Stereotyping involves making assumptions about the characteristics of individuals, which are based on a standard, simplistic characterisation of their culture.

Awareness and application of these issues helps to define what is meant by cultural competence. Cultural competence is much more than awareness of cultural differences, as it focuses on the capacity of the health system to improve health and wellbeing by integrating culture into the delivery of health services.

To become more culturally competent, a system needs to:

• Recognise and value diversity;
• Have the capacity and motivation for cultural self-assessment;
• Be conscious of the dynamics that occur when cultures interact;
• Institutionalise cultural knowledge;
• Promote and value reciprocal relationships as the starting point for health care interventions, based on mutual learning, trust and respect;
• Ensure service provision responds to the needs of people from diverse communities and their carers, and recognises the role of traditional health beliefs and practices and informal support networks; and
• Ensure health care interventions are evidence-based or informed, and reflect Australia's cultural diversity in their design and implementation.

And the best way to begin system change and reform is to nurture and support people from diverse backgrounds as respected and knowledgeable. After all, they are the experts on the topic of their experiences. For some they can be our teachers on how to survive alone, form friendships, and build communities even when you don't speak the same language.

Moving away from the key messages of the NHMRC's Cultural Competency in Health, consideration must be given to the role that universities can play in promoting partnerships and participation. For some mental health academics they will need to be more open to the importance of culture and meaning. The National Action Plan on Mental Health calls for collaboration across education, clinical and research sectors. Through sustainable clinical relationships, practice development and research into service effectiveness, university health departments and industry partners can make a difference in this new era.

Senior academics and professors in particular must lead and develop new alliances between universities and mental health services. In some instances this will mean making radical changes in the way university academics relate to their clinical and industry colleagues.

The idea here is for the university sector to design research and clinical education as community engagement programs from the perspective of industry - understanding how they will experience it, using their language, and incorporating their priorities.

Why is this important? Because funding and prestige pressures within the higher education sector may tempt universities to approach the problem inside out, putting a research or education program together in ways that make life easier for the university rather than the consumer of mental health services.

Where to begin? The first step is to value relationship capital: the quality time we spend with each other, understanding the way we think and respecting each other's point of view. For industry partners this means evaluating and explaining the relevance and value of service aims and objectives as perceived by consumers and mental health service providers. As this dialogue matures new insights develop.

This process drives up trust and leads to a cross business language that facilitates collaboration from all sectors on where to look for birthing good ideas and how to use internal structures to leverage them. In the mental health sector this encourages clinical and administrative leadership and a clear service improvement strategy with human rights, social justice and equity values.

University professors in mental health must know what they stand for, how they will work with multicultural Australia, how they will create teamwork, and how their actions will create and facilitate sustainable benefits for mental health consumers.

And now it's over to us all. As clinicians and academics, practice change is within our reach. Australia is not unique in recognising the value of a culturally competent health system and its potential to improve health outcomes for all. The challenge for clinicians, administrators, policy writers and university professors is really about knowing the people in their community now or those they are likely to have in the future, and working backwards.

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