Demystifying mental health in CALD communities.My presentation draws on a multicultural mental health awareness project that the Australian Multicultural Community Services (AMCS) undertook in partnership with the Arabic, Cambodian, Chinese, Polish and Macedonian communities in Melbourne. I will also draw on my experience as a CEO of a multicultural service organisation, and my in depth knowledge of the Polish community and mental health issues experienced by that community. I am of Polish background myself and have authored and co-authored publications about Polish migrants in Australia. To start with I would like to mention some statistical information as a way of setting the context. As you may know, for the fourth year in a row, Australia was identified as one of the best countries to live in according to the OECD Better Life Index. Next in that category are Norway, Sweden, Denmark, Canada, Switzerland, USA, Finland, Netherlands and New Zealand. Australia scored well in 11 measures of well-being, including: income, state of the natural environment, safety, health care, quality of education and general life satisfaction.

Despite our economic improvements, affluence, and the good life that many Australians have generally, we know that the number of people experiencing mental health issues is increasing in our country. I refer here not only to psychiatric illnesses such as schizophrenia or other psychosis, but also many other disorders that cause suffering, for example depression, difficulty in adjusting or functioning well in the community, phobias, and dementia. We know that between 20-25% of people in the Australian community experience some sort of mental illness, at some point in their life. We also know that mental health issues affect all age groups, all communities and all ethnic groups in multicultural Australia.

One the most significant indicators of the extent of mental health difficulties experienced by people are the number of suicides. Australian Bureau of Statistics data shows that in 2012, 1901 males and 634 females died as a result of suicide, that is a total of 2535 deaths, which equates to an average of 7 deaths by suicide in Australia each day. Statistical data also shows that between 2008-2012, the highest state based suicide rates were in Northern Territory and Tasmania, followed by Western Australia, Queensland and South Australia. In contrast, Victoria, the Australian Capital Territory and New South Wales had the lowest rates of suicide. In Victoria, 502 people committed suicide in 2012. The suicide rate in Australia is close to the highest it has been in a decade, according to figures from the Australian Bureau of Statistics, leading experts to declare this issue an ongoing "national tragedy".

The statistics show that 75% of all people who took their own lives in 2012 were male, with the highest rate of suicide being in the age of 85 plus age group. This is important information, given that this conference is about quality in aged care. Older people and mental health is a topic that has only quite recently been a focus for policy development with the World Health Organisation recommending six strategies for improving the mental health of older people in 1987. Those recommendations included: early prevention of the unnecessary loss of functional capacity, assistance for the elderly to live in their own homes, prevention of unnecessary admissions to residential care, prevention of breakdown of informal networks of care particularly family connections.

Let me now mention a few statistics for Victoria. In that state, the number of people over 60 years is expected to increase from 1 million in 2010 (19 per cent of the population), to 1.4 million in 2020 (23 per cent). By 2030, one quarter of the Victorian population will be over 60. The number of people over 85 is projected to have increased from around 100,000 in 2006 to around 300,000 in 2036.  

The life expectancy for Victorians at age 60 is 83.4 years for man, and 86.5 years for women, according to the Victorian Population Health Survey 2007. The Department of Human Services Survey of Victorians aged 60+ showed that 79 per cent rated their health as excellent, very good or good, but 71 per cent were at risk of psychological distress. In view of the particular focus of my presentation, it is important for decision makers and aged care providers to also know that 40 per cent of people over 65 years of age, from non-English speaking backgrounds speak English "not well" or "not at all" and this has implications with regards to age care. The most common mental health disorders within ethnic ageing communities are: depression, memory loss, age-related dementia, and anxiety.

Further, on the basis of the Victorian Population Health Survey, we can estimate that about 50% of older people suffer from depression, and within that group about 20% experience other forms of mental illness. Depression in older people often relates to feelings associated with the end of life, loss of independence, physical pain, being excluded from the community, feelings of loneliness, or being a burden to other family members. Let me now talk about migrant mental health. The majority of mental health illnesses are universal, they affect all cultures and all communities. But I believe it is appropriate to ask whether and to what extent there is a correlation between mental health and ethnicity? Theorists' and practitioners' views vary on this question. But they seem to agree on the notion that the cultural background of a given person, does affect the way they experience mental disorders.

ABS data shows that in 2011, 27% of the Australian population were people born overseas. Victoria is one of the most multicultural states in Australia; just over 40% of Victorians were born overseas or have at least one parent who was born overseas. Many of its new settlers come from countries that experienced war or political upheavals. Another relevant question to ask at this presentation is: Does migration increase the chance of a person experiencing mental illness?

It is well known and I can confirm personally that migration is often very stressful. The experience of migration includes a large number of stressors; up-rooting yourself from a familiar environment, your family, the traditions that you know and the sudden change to something different, combined with the need to learn, adjust and still manage your life, even if you cannot speak the language of your new country of residence. Australia is a land of migrants. Many have come here for a better life, some escaped prisons, many come from oppressed societies and feared for their life or have experienced torture. We can infer with a high degree of probability that people who have had horrific experiences, are likely to be more prone to experience mental health issues, compared to those who have lived in stable and politically safe environments.

As someone who has worked mainly with Displaced Persons who settled in Australia following World War II, I know that the majority have experienced atrocities personally or have witnessed atrocities inflicted on others. I continue to have the highest regard for that generation of migrants, who despite these experiences, and unimaginable hardship, have established their lives in Australia and as much as possible, continue to focus on the positive side of life. However, for many, memories of trauma continue to affect their behaviour.

To illustrate, I would like to share Teklamena's story. Teklamena is a woman of Polish background, 89 years of age, who lives in an aged care facility in Melbourne. She came to Australia in 1962. She was born as an illegitimate child and experienced a lot of prejudice because of that, from her own family and also the local community. From five years of age, she had to look after her three year old brother. During World War II when she was 16 years of age, she was taken as forced labourer to Germany. Towards the end of the war in 1945, she was raped by Russian soldiers when the Russian army entered Germany during the liberation movement. Such rapes on Polish women were not a one-off occurrence. As soon as she was able to leave Germany, she walked thousands of kilometres back to Poland. Upon return she began to work as a cook in a factory. She was a highly religious person but due to her traumatic experiences during the war, she no longer believed in God. Her experiences also resulted in a complete aversion to men.

Staff in the aged care facility where she now lives have identified a range of odd symptoms in her behaviour. Teklamena is at times aggressive and intimidating towards other residents and staff, especially towards males. She often displays a high degree of fear, sometimes she hides in the toilet or in bushes in the garden at the facility. The best thing that aged care providers can do in ensuring quality in aged care is to ask an older person: can you tell me about your life? With regards to migrants, it is also important to ask: can you tell me about your life prior to coming to Australia?

Now, I would like to present a study that AMCS undertook, which revealed perceptions and attitudes towards mental health issues among ethnic groups.

The Demystifying Mental Health in Ethnic Communities project was undertaken within five different ethnic groups. AMCS chose these particular communities, as they were identified as under-utilising mental health services and had similar issues around the migration experience i.e. members of their community were forced to leave their countries of birth as a result of war, political conflict and other traumatic events. AMCS worked with the following community organisations during the project: the Cambodian Community Welfare Centre, the Chinese Health Promotion Foundation, the Macedonian Community Welfare Association and Victorian Arabic Social Services. I would like to acknowledge that funding for this project was obtained from The William Buckland Foundation and from the Coles Group Community Grant Program.

The project aimed to:
*raise awareness of the mental health needs of those communities;
*provide these communities with culturally and linguistically appropriate information about available services;
*raise awareness about issues faced by CALD communities;
*contribute to discussions that could influence the development of better mental health services;
* promote access to mental health services;
*produce resources to enable these communities to gain a greater understanding of how the mental health system works in Victoria;
*promote strategies addressing preventable mental health conditions, thereby reducing the need to access services.

The project enabled us to learn about some of the perceptions that are held within those communities. With regards to the Arabic-speaking communities - the views collected came from feedback from two focus groups conducted with Arabic-speaking community workers and community leaders. We found that mental illness is viewed in negative terms in those communities, with the resultant stigma significantly impacting upon the whole family. Community representatives made comments like "Mental health is like cancer, people do not easily discuss the diagnosis. It is seen as a form of weakness in the community. Some people will be labelled as "crazy" as a result of it". As with other CALD communities, the Arabic-speaking population has little knowledge about available services, and it is not accessing them until a situation reaches a stage of crisis. The Victorian Arabic Social Services (VASS) is often the first resort for assistance for those with complex mental health issues.  

With regards to the Cambodian community - approximately 10,000 Cambodians reside in Victoria and many have experienced war in their home country. The project that AMCS undertook involved discussions with Cambodian seniors and other community members. We learned from their comments that many families may try to deal with mental illness "in house”, in order to avoid outsiders becoming aware of any problems. People who talk about their mental health problems risk being ostracised by their family and social network.

Most participants had limited understanding of the different types of mental illness - they associated the words "mental illness" with aggression, and described it as “brain illness”, or “it is a problem of many thoughts in your head". The majority of participants believed that mental illness is associated with bad spirits, bad karma or witchcraft. They agreed that the Cambodian community generally believe that great shame is brought onto a family when one of its members becomes mentally ill. Comments made included and I quote: "I think people feel shame. I know of one family and they didn’t tell us, they didn’t come to our house for a long time for this reason", end of quote. Where do people go to seek help? For some it is the local Cambodian Buddhist temple and Cambodian monks, or a priest.

Another community in this project was the Chinese community. According to the 2011 Census, it is the largest CALD community comprising just over 176,000 of Mandarin and Cantonese speakers. In relation to the perception of mental illness in the Chinese community, most people follow a traditional model based on Chinese medicine, which attributes any illness to negative energy and imbalances within the body. Therefore, mental illness is not viewed as being an intractable problem. Nevertheless, there is a strong sense of shame attached to the whole issue of mental illness, especially when it is "acute" or "very serious".

In general, people in the Chinese community appear to have a limited understanding of what forms mental illness can take. The perception of mental illness in the Chinese community appears to be heavily influenced by the media and often associated with violence and harm caused to oneself or others. This perception is further reinforced by peoples' assumptions and stereotypical views of the mentally ill as being violent and causing harm and injury. Many people agreed that the community don’t view mental illness in the same way as other illnesses. Consequently, a person with mental illness is likely to experience discrimination in the community.

Whilst many agreed that the Australian Government is generous with general health care, they felt that insufficient resources had been allocated to supporting people with a mental illness and to community education.

With regards to the Macedonian community, it is estimated that around 33,000 Macedonian background people live in Victoria. It is a community that faces specific cultural stigmas associated with mental health. In particular, lack of education, knowledge and access to information are the major contributors to this issue. The majority of the Macedonian community does not view mental illness as an authentic illness, but more as a burden and a source of shame to the family. There is a belief that the individual, or the individual's family, are to blame for the mental illness. These perceptions come from two groups - a Macedonian- speaking youth group and a Macedonian-speaking senior citizens. Although both groups had an understanding of what mental illness is, it was evident that the youth group were more knowledgeable on the matter in comparison to the seniors. As well as this, the younger participants often only referred to depression and schizophrenia as mental illness, whereas the seniors were only aware of dementia as being a mental illness.

Additionally, many people within the Macedonian community are unaware that there are measures that can be taken to prevent mental health problems. As well, the fear of being negatively judged by others in their community often leads to denial about the illness. This results in those affected by mental illness either hiding away, or hiding their emotions, creating greater problems for their own physical and mental health, as well as creating potential problems for the next generation. Some believed that going to church and being forgiven for one's sins would cure the illness or that "death was the only cure"

The youth group commented that they would initially go to a friend or sibling, but would not go to a parent, because they believed their parents would simply ignore the issue, for fear of what people might think if it turned out to be a serious issue. It can be concluded that there is a serious stigma associated with mental illness within that community. With regards to the Polish community, the 2011 Census indicated that there were 48,500 Polish people living in Australia. Polish elderly comprise Victoria's fifth largest ethnic group among our elderly population and the second largest non-English speaking population aged 85 years of age and over. The percentage of members of the Polish community who arrived as refugees to Australia is the highest among all ethnic groups.

Most Polish migration to Australia occurred in two waves. In the early post -World War II period, predominantly between the years of 1947 and 1953, an estimated 60,000 Polish persons arrived as refugees under the Displaced Persons Program. During WWII, Poland was occupied by Germany from the west and Russia from the east. Six million Poles died in total during the war years. Furthermore, many Poles had no home to return to due to the changes in Poland's borders following the war and the communist regime being imposed in Poland by Russia.

What do we know about mental health problems among members of the Polish community? Research to-date shows that Polish people were over-represented in admissions to psychiatric facilities, in comparison to other CALD communities. Their older age and accompanied age-related illness eg. depression, dementia, Alzheimer's combined with the refugee status of earlier immigrants and lack of family networks, are likely to account for this over-representation of the older Polish migrants using mental health services.  

Other research suggests that there was a presence of hidden grief and loss among that group. Despite the efforts to forget the past, the participants indicated that they still remember and have dreams about the war, which result in deep depression.

In this project about demystifying mental health, the participants in the first focus group comprised ten Polish-born women aged between 40-60 years. The second group comprised eight Polish-speaking seniors aged between 70 to 80 years. They varied as to their socio-economic status, level of education, and family composition. Participants held the belief that depression does not constitute a mental illness and was described as "dullness and isolation". Mental illness, along with other forms of disability, has traditionally been viewed in Poland as a personal weakness and failure. The consensus among participants was that if one is in trouble, people are not very willing to help and that in today's world people are very busy and do not have time or energy to look after others.

According to these participants, people were “slipping through the net”, unless they have dedicated family members or friends who are able to support them. Support in combating mental illness is generally expected from peers, close relatives and friends. Additionally, although several participants admitted to utilising professional mental health services, it was noted that there is still an element of stigma attached to seeking assistance from health professionals. Group participants mentioned that those with a mental illness may find it difficult to access available services, with language being the main obstacle. The language barrier is particular significant amongst the elderly.

According to participants, the more conservative and family-oriented Polish sections in the community, attended church and the role of religious representatives is recognised as a strong protective factor, not purely for spiritual reasons, but also because it facilitated social networks.   The seniors participants believed that their generation is specifically affected by mental illness because of their war-time experiences most of which they endured during their youth. They experienced torture, displacement, removal for slave labour to Russia or Germany, and fear for their family and friends. In some cases the experiences of the past have left permanent scars. Many of them have become socially withdrawn and spend much of their lives re-living their sadness and sorrows.

Generally the participants understood the concept of mental illness, and were more aware of the prevalence of it. They listed different factors contributing to the development of a mental illness, including: alcohol, drugs, problems at work, and divorce. Furthermore, Polish elderly felt that the death of close relatives or friends (husband, wife or child) were important factors contributing to mental problems. General practitioners were reported to be the main source of information when in need of services.

Overall, the following conclusion can be made about the perceptions of mental health within five ethnic communities The research has confirmed that a significant portion of the CALD population views mental health differently. We can also conclude that their families and carers are unlikely to seek help when experiencing mental health issues. Often this happens, due to a number of factors including language and cultural barriers and the stigma associated with mental illness. Also, CALD migrants may not have sufficient information about available services and how they work, lack information about mental health in a language that they can understand, or there may simply be lack of CALD appropriate mental health services.  

The five project officers who undertook this project, came up with the following recommendations:
There is a need for:
* increased understanding of mental health issues within diverse communities, thereby reducing isolation and stigma;
* increased support for CALD communities regarding mental health issues;
* increased access services prior to crisis intervention;
* increased usage of funded counselling services

Summary - Let me conclude:
Living with a mental illness is often a silent phenomenon for the person affected by it, as well as his/her carer(s). Ideally, it requires the implementation of ongoing awareness campaigns, challenging the stereotypical views surrounding mental illness, together with health promotion strategies and programs specifically targeting members of migrant and refugee communities.

In my presentation, I referred to our ageing population, and the particular needs of elderly migrants of culturally and linguistically diverse backgrounds. With the significant number of older people from ethnic migrant backgrounds increasing, it’s becoming more urgent to develop culturally and linguistically appropriate service responses. Also, we as service providers and government representatives cannot ignore the fact that the highest number of suicides is amongst the 80+ aged population. We need to do something about it, to do it as soon as we can, not in five or 10 years time.

Elizabeth Drozd
Chief Executive Officer
Australian Multicultural Community Services