In recent years, there have been significant calls for the increase of consumer led training and education for mental health workers. Various reports have detailed many strategies for including consumers as key partners and ‘teachers’ in developing knowledge, educational content, delivery methods and other learning methods (Epstein and Shaw, 1997; Mental Health Council of Australia, 2000).

In the literature, consumer led education has been characterised by the themes of: valuing lived experience of illness and health as a basis of knowledge; consideration of the whole person; valuing personal identity and history; inclusion; improving communication; and therapeutic relationships (Deakin Human Services Australia, 1999).

Talking about consumer and carer led education in the context of transcultural mental health adds further layers of exploration, given the unique areas of cultural knowledge and experiential background which CALD consumers and carers bring to their participation in mental health services.

This paper is written within the context of my current research with consumers, carers and transcultural trainers in this area. As an interpretive, ethnographic study, my work has been to develop an understanding of the types of roles these participants undertake in the educational environment with mental health workers and the areas of knowledge, experience and networking they utilise in providing learning opportunities. The content presents both questions I have about the topic and also an emerging understanding1 of some the work being done in this important area.

CONSUMERS AND CARERS2 AND THE EDUCATION OF MENTAL HEALTH WORKERS
Linking the organised consumer movement or individual consumers to training in mental health care is a growing subject amongst the general movement. In many documents on consumer involvement, the area of training is usually raised in terms of the training required by consumers to work as effective advocates or consultants. There have been, however, a number of Australian projects focusing on consumer led training where mental health workers are seen as the target of educational processes. This focus has also been reflected and pursued within national level reports on workforce development and reports on consumer participation and education. These include the Commonwealth’s 1999 Learning Together: Education and Training Partnerships in Mental Health, which centered on the educational needs of the mental health professions and the Mental Health Council of Australia’s report Enhancing Relationships between Health Professionals and Consumers and Carers, which detailed various recommendations for improving consumer centered mental health care. There is also the recent National Practice Standards for the Mental Health Workforce which produces guidelines for practice as well as advice on education curricula (National Mental Health Education and Training Advisory Group, 2002).

The Learning Together report highlighted the need to ensure that professionals acknowledge the various levels of expert knowledge held by consumers on experiences relating to their mental health and preferred mental health care. The recommendations’ desire for reform, stated that:

“Agreement exists between all representative participants of the five disciplines and carers and consumers at the workshops that reform of current education and training in universities, and continuing professional education in the workplace is both necessary and possible…All such reforms, (that is, their structures and processes) need to be assessed against the Statement of Principle, i.e. the relationships between consumers and service providers and carers and service providers, should be the primary focus of practice and research in mental health. Consumers and carers are therefore major players in the education, training and development of the mental health work force”(Deakin Human Services Australia, 1999 p. 1)

The report also set out two major principles in how education and training structures and processes must be developed. These are that “mental health professionals need to learn about and value the lived experience of consumers and carers” and that “mental health professionals should recognise and value the healing potential in the relationships between consumers and service providers and carers and service providers” (ibid. p. 1).

Also, in terms of professional knowledge bases, the report considered that “each discipline needs to develop a new body of knowledge around the “lived experience of consumers and carers” (ibid. p. 1).

A report by the Mental Health Council of Australia responded to these recommendations, suggesting that many strategies would be required to achieve the intent of developing consumer centered training. The Council’s own list of requirements covered areas such as strengthening links between consumer and carer educators and education providers, redeveloping educational curricula for professionals, implementing innovation in educational methods and promoting positive, whole of life perspectives in professional education rather than an exclusive focus on diagnostic based knowledge (Mental Health Council of Australia, 2000 p. 53-55).

Many of the themes throughout the consumer participation literature offer considerable challenges to the typical ways in which the mental health professions teach about emotional and mental health. For instance, the themes of valuing lived experience of illness and health as a basis of knowledge and valuing personal identity and history impact not only on what is taught but also who has the authority to teach. These themes also reflect on how experiential knowledge can be valued alongside the typical abstracted, scientifically driven theories and explanations within mental health professions.

One of the features of experiential knowledge in various health care issues is that it is usually expressed in the person’s own biographical and situational context (Popay, Williams, Thomas and Gatrell, 1998; MacDougall, 2001). Their experience, development of interpretations and subsequent experiences occur in their real life context with personal real life costs. A number of authors commenting on this area suggest that traditional discourses about health and illness, as well as positivist research methods, limit the appreciation and use of community knowledge in articulating health issues and their resolution. It can be implicitly devalued as ‘lay knowledge’. However, as community members talk with each other about their experiences of health and health care services, they can begin to develop shared understandings of what environmental and social factors contribute to undermining as well as improving their state of health.

“Lay knowledge differs from expert knowledge in the sense that it has an ontological purpose, orientating behaviour in terms of an understanding to the individual’s place in their life-world. It is…. expressed in narrative form. This form is antithetical to traditional models of cause and effect, such as those given prominence within the inequalities research literature. Second, insofar as such narratives draw on or relate to wider public narratives (or discourses) they may also constitute a form of knowledge that challenges that of experts” (Popay, Williams et al., 1998 p. 640).

VALUING CONSUMER AND CARER KNOWLEDGE ALONGSIDE DISCIPLINE BASED PERSPECTIVES
The efforts of consumers, carers and professionals to work towards undertaking new forms of education for professionals have seen some very creative and challenging projects within Australia.

One of the central features of this work has been a movement of generating dialogue between consumer perspectives and discipline based knowledge, with some projects including carer perspectives also. In a project in Melbourne for example, the education of psychiatric nursing students involved educational sessions on the consumer perspective, which was taught alongside more traditional nursing content. In reporting about her work, the consumer educator in this project noted how the consumer perspective offered a critique of usual nursing practices and requested that students sit with problematic areas of content.

“…… The idea was to include a consumer perspective on an existing subject. I seldom used my own personal experience to demonstrate a point, and students could access a wide range of reading materials written by consumers held at the Centre. The focus of the subject was largely on how the whole psychiatric system impacts on both consumers and nurses. The one message that crystalises what I was attempting to do would be that while in their role, nurses have to do things that would otherwise be unconscionable, and to honour both the consumer and themselves, they will need the ability to hold a knowledge of both their own sense of ‘duty of care’ and also appreciation of doing damage to another through, for example, a treatment against another’s will. Both are real, and both are difficult. The structure of the course, remaining as two sometimes mutually exclusive perspectives, ideally left students needing to be aware that problematising accepted practice in the light of a consumer perspective, or even a human rights perspective, is a necessary part of psychiatric nursing” (Centre for Psychiatric Nursing and Practice and Melbourne Consumer Consultants’ Group Inc., 2001 p. 13) (see also Happell and Roper, 2002).

One of the key features about this work, is that listening and learning from the other, is seen as an integral dimension of professional development. In this sense, students learn about the effects of professional practices from the people who experience them. The experiences of consumers and carers in mental health become related not only to aspects of emotional and mental distress, but also to whether services are useful or not. We can see from the above example for instance, that this particular consumer oriented education contained an evaluative feature which raised the level of accountability of professionals to consumers and carers.

IN THE TRANSCULTURAL LIGHT
In the transcultural sphere the movement of consumer and carer education is more complex and challenging. The socioeconomic and political status of many CALD communities, reported to be on the periphery of mental health planning and decision making concerns, suggests that the level of disadvantage in organising and being heard in a consumer mental health movement is high. The range of various service related, historical and cultural issues which impact on CALD community participation within mental health is reflected in the relatively low number of CALD consumers and carers acting as advocates and educators (see e.g., Sozomenou, Mitchell, Fitzgerald, Malak and Silove, 1999).

It is important to recognise that participation of CALD consumers, carers and community members in mental health is very different from the general consumer and carer participation movements. Many of the issues relate to the great diversity of community groups and languages, the differing feelings around participation rights within community groups and community discrimination around mental health as a public concern (Sozomenou, Mitchell et al., 1999).

The less visible status of different CALD communities in mental health means also that the experiential knowledge of culture, mental health, minority status etc., is rarely included in research activities which contribute to mental health knowledge bases. This gap in knowledge is one where community members as people experiencing mental health concerns and their carers have an important position in being involved in producing knowledge and sharing knowledge in educational contexts. One of the recent projects in this area, the Reciprocity in Education project (see page 10 of this issue of Synergy), indicated that community stories, learning and knowledge can be generated into effective educational experiences and materials for workers. This knowledge could only be generated from the people whose lives have been greatly affected by experiences of migration, settlement, trauma, a bicultural life, seeking help for emotional and mental distress, caring for others etc. (Amirghiasvand, Eaton, Engelhardt, Moutakis and Procter, 2001; Aylward, 2001).

In this realm of education, CALD community members play an important role in describing experiences and developing, where possible, a more collective orientation towards preferred mental health services and practices. The general consumer movement has a history of valuing personal story telling as well as the development of consumer perspectives, which can be seen as a body of preferred principles and critical views about mental health and services. In this respect, consumer and carer educators have a choice of speaking from a personal point of view, or from a collective perspective of shared history. In transcultural education, CALD consumer and carer educators can provide opportunities for workers to consider the connections between culture, migration, health, caring and service provision.

CONCLUSION
One of the important learnings from the movement towards consumer orientated mental health education is the effort to ‘democratise’ a key area of knowledge production and distribution in mental health. Education and training environments and processes have been recongised by consumer advocates and representatives as places where claims are made about people’s mental health, emotional status and required care (Brown, Kordas and Reeves, 1993). The involvement of consumers and carers, with their various experiential perspectives, provides a different basis to describe mental health, illness and care as compared to professionally derived knowledge. This different positioning offers a considerable challenge to professionals as well as potential for a richer understanding of the social, experiential, lived aspects of people’s lives in relation to mental health and distress. It offers also a possibility to uphold the human dimensions of mental health care and a space to consider how more technically oriented frameworks and approaches to care impact on people’s internal and expressed sense of humanity.

From the transcultural viewpoint, this human rights positioning emerges from another angle where participation is about the experience of cultural and linguistic difference and similarity as well as health. The participation of workers in these learning contexts may help them to explore the cultural basis, and cultural limits, of their own practices and local services. As this exploration can occur in dialogues with consumers, carers and others, there are ongoing opportunities to develop ideas for practice which are open to the diverse interests of local communities.

Footnotes
1 As the research is currently in early stages of data generation, most of my focus in this paper is on published literature rather than the views of participants contributing to the research. I would, however, like to acknowledge and thank the participants for their generosity in sharing their knowledge and views with me. Their interpretations have undoubtedly shaped my thinking in this area.

2 I’d like to point out that both carer and consumer participation in education are two separate dimensions of perspective and representation. Some of the reports noted do not draw out specific notions around the different roles of each perspective.

References

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