Pathways of recovery: preventing further episodes of mental illness (monograph)
Australia has a culturally and linguistically diverse population, with many residents born overseas and originating from non-English speaking countries. Australia is also home to refugees, who have a unique and often traumatic experience of migration. Considering relapse prevention within a multicultural context requires understanding the differences that arise through cultural and linguistic diversity.
A factor that has an overriding impact in terms of relapse prevention for people from culturally and linguistically diverse backgrounds, particularly those from non-English speaking backgrounds, is that they are less likely to access mental health services. There is a marked reluctance among many people from culturally and linguistically diverse backgrounds to voluntarily access both hospital and community-based mental health services (McDonald & Steel 1997, Minas et al 1996). This lower level of service use is not related to lower levels of need, but rather to difficulties in understanding and accessing mainstream systems of care and lack of access to services that are culturally safe and appropriate.
Stigma, lack of information about mental illness and mental health services in appropriate and accessible formats, and poor communication and cultural differences between clients and clinicians have been reported as major barriers to timely access to mental health services (Long et al 1999). Lack of access negates the early intervention and ongoing partnerships with service providers that are essential for relapse prevention. Furthermore, lack of early intervention contributes to the reality that people from some culturally and linguistically diverse communities are overrepresented among involuntary admissions and forensic populations.
The stigma of mental illness has a particularly strong impact in some cultures and is a significant barrier to early and effective access to services. While stigmatisation of mental illness is universal, the importance of privacy related to such matters is stronger in some cultural groups than others (Raphael 1997). Reducing the stigma of mental illness is, therefore, a priority in many transcultural contexts to encourage and support consumers and their families and carers to access the services that they need to manage risk of further illness.
The role of families is of primary importance in many culturally and linguistically diverse communities and approaches to relapse prevention must recognise this. In many transcultural contexts it is the family, rather than the individual, that must be the level of focus for interventions to encourage awareness of mental health, anticipation and planning related to preventing relapse, and access to the range of clinical and non-clinical supports that may be required to support someone at risk of further episodes of mental illness.
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Consumer participation and empowerment have been identified as being essential to relapse prevention, yet there are unique challenges to involving consumers, carers and communities from culturally and linguistically diverse backgrounds in mental health (Sozomenou et al 1999). There is a relatively small number of consumers and carers from culturally and linguistically diverse backgrounds acting as advocates and educators in mental health. Due to the great diversity of community groups and languages, diverse feelings around participation rights within community groups, and community discrimination around mental health as a public concern, additional supports need to be put in place to increase participation. Involvement need to be facilitated at all levels: from community advocates to participation in individual illness management plans. Importantly, the development of self-help groups that support consumers and carers from different cultural and linguistic groups needs to be prioritised to provide social support, information, role models and advocacy.
It is very hard and lonely here. I do it all on my own. Sometimes I wonder whether I should take my son home. In my country there would be more people to give us support. There is a different system there where there is much more support for people like him. He might even be able to get a job. Here there is only me: I have to do it all. It's very tiring, but I can't ever give up. —Carer
The role of the general practitioner and other primary care providers has been highlighted for transcultural mental health care (Mihalopoulos et al 1999). GPs are often the first and only point of service contact for many consumers from culturally and linguistically diverse backgrounds and their families and carers. This relates partly to the pronounced impact of stigma, but also to other barriers that limit access to mental health services and other community services. Consequently, for ongoing monitoring and illness management for people who have experienced a mental illness, the GP may play an even more important role in a transcultural context, and this requires additional skills and supports for the GP.
The cultural competence of service providers, both clinical and non-clinical, is essential to relapse prevention for people from culturally and linguistically diverse backgrounds. Health providers need to be culturally sensitive in their assessment, diagnosis and management of clients. While these are areas of continuing need, some relevant resources have been recently developed including a revised, national version of the Cultural Awareness Tool (CAT), which is available to facilitate practitioners' understanding of their clients' explanatory model of their presenting problem (WA Transcultural Mental Health Centre 2003).
Working in a transcultural context requires 'awareness, knowledge and skills' (Gabb 2000). This means, firstly, an explicit awareness of the cultural values involved in the relationship between service provider and client. There is then the need to understand significant events and experiences that impact on wellbeing: a process that is especially relevant for those with experiences of torture, trauma, displacement and loss. Finally, there are specific skills required for working with people from diverse cultural and linguistic backgrounds, such as working with interpreters and being aware of verbal and non-verbal communication differences. While training in cultural competence is recognised as a necessity in many services, in others, and particularly in some of the support services sectors, there is little provided in the way of such training.
Risk and protective factors vary across culture, as well as by age and gender (US Department of Health and Human Services 2001). Poverty, immigration, violence, racism and discrimination are some of the risk factors that disproportionately affect racial and ethnic minorities, especially refugees. Fundamentally, opportunities and access to the basic living requirements that promote wellbeing, such as accommodation, work, education and leisure activities, can be reduced for people from culturally and linguistically diverse backgrounds.
Conversely, protective factors such as spirituality, community and family support can be stronger in some communities, and these can be drawn upon to support the wellbeing of people who have experienced mental illness. It is important to encourage community members to talk with each other about their experiences in order to begin to develop shared understandings of the environmental and social factors that comprise the risk and protective factors for mental health within their communities (Loughhead 2003), and to determine ways to impact on these to reduce the stressors and improve the supports that will facilitate the wellbeing of people who have experienced mental illness.