This brief article summarises the findings of a much larger report on “Care-giving and the social construction of ‘mental illness’ in immigrant communities.” This report was launched on March 9th 2001, and provides a full account of our investigation into how carers’ understandings and experiences of ‘mental illness’ and their utilisation of support services are influenced by factors such as culture, language, the experience of migration, and social relationships. Carers were drawn from the Bosnian, Chinese, Croatian and Polish communities of Perth, Western Australia.

Qualitative methods were employed in order to investigate the support services available to the carers of people who have been diagnosed with a ‘mental illness’; and the informal support systems utilised by carers from immigrant communities. Focus group discussions with community members and in-depth semi-structured interviews with carers and health and mental health practitioners were conducted. In these, we explored carers’ understanding of mental health and illness; their ‘help-seeking behaviour’; the roles they played in the lives of their relatives; and their lived experience of the settlement process in Australia.

Major Findings
Care giving was described as an exhausting and ongoing duty. Most of the carers interviewed stated that there was simply no one else available to help. Many carers regarded caring as exclusively a family responsibility. In addition to financial burdens, social isolation and disruptions to daily life, considerable pressure is often placed on carers and their families. Some carers reported distress and frustration, and a number of carers described periods of verbal and physical violence. Many carers expressed a strong desire for ‘time out’, or for some relief from their roles. However, none of the carers interviewed were aware of any of the support services available to them, and indeed, many were more concerned with obtaining social support for their distressed relative. One carer suggested that there was a need for greater community acceptance of people diagnosed with ‘mental illness’, and that this kind of ongoing ‘community support’ would facilitate the ‘resumption of a normal life’, for both people with problems in living, and their carers. Carers also requested access to material forms of assistance. That is, help with mundane duties such as house and garden maintenance, and access to services such as ‘Meals on Wheels’, and childcare. However, it was also noted that a thorough assessment of the particular needs of individual carers should always precede any offer of service or support.

Many carers reported that they were ‘coping in isolation.’ A number of participants asserted that some families have isolated themselves out of fear of stigma and ostracism from their community, and out of the conviction that caring for ‘the mentally ill’ is exclusively a family responsibility. The social isolation of carers from immigrant communities may become more pronounced through difficulties in acculturation, broken social networks, discrimination and racism, socioeconomic restrictions, and due to the stigma often attached to ‘mental illness’.

Stress, migration and mental health
A strong theme that emerged from the interviews was that of the impact of migration on mental health. Many participants considered migration to have a significant impact on mental health, and were adamant that these issues needed to be taken into consideration in any discussion of mental health and illness in immigrant communities. It should be noted that these participants also stressed that many of the mental health issues faced by migrants are similar to those faced by the ‘mainstream community’. With regard to the effects of migration on mental health, participants reported that the isolation and loneliness experienced by many recent migrants often leads to psychological distress, and that the absence of support in stressful situations may exacerbate this distress. Further, people may grieve for the loss of their family, friends, and familiar way of life. Others may experience a ‘postponed reaction’ to the migration experience. A number of participants reported that ‘cultural clashes’ between generations may be a further source of psychological distress, and that young migrants may experience ‘peer pressure’ and discrimination.

Some participants argued that migration itself is not the major precursor to the development of mental health problems, but may be a risk factor for mental health, and that this is particularly the case for refugees. A number of participants asserted that the manifestation of mental health problems related to traumatic experiences is dependent upon the circumstances that exist after settlement. The stress of resettlement may compound ‘traumatic dislocation’, which can result in mental health problems. The loss of status due to unemployment, or downward mobility, may render people from immigrant communities particularly prone to psychological distress.

A number of participants reported that people are often more tolerant and supportive of the ‘mentally ill’ and their carers within smaller, close-knit communities. Some participants noted that people diagnosed with a ‘mental illness’ are less likely to be stigmatised if there is seen to be a precipitating ‘cause’ (for Bosnian and Croatian groups, recent war experiences were frequently cited as a cause of ‘mental illness’). It was also reported that people from cultures more proximal to the ‘Anglo-Australian’ culture may be more likely to benefit from existing support services, and that religious groups may provide a vital support mechanism for some groups.

Speaking openly about ‘mental illness’ was described as ‘interfering in other people’s problems’, and as being culturally inappropriate. Participants from all four cultural groups reported that ‘mental illness’ was heavily stigmatised in their communities. A number of participants suggested that mental illness’ may be ‘destigmatised’ via more information about forms of psychological and psychiatric treatment, and through professional explanations that emphasise ‘normal responses to life’s problems’, and ‘stress management’, rather than ‘madness’, and ‘illness’.

From the carers’ accounts, it is evident that health and mental health systems are often not sensitive to differences of culture and language.The service providers interviewed also drew attention to the need for ‘mainstream’ services to become more culturally competent. Carers also reported difficulties in communicating with service providers, and that they found it hard to gain access to clear explanations about the ‘condition’ of their relative. These difficulties are compounded by the fact that mental health information is often only available in English.

Communication difficulties
Communication issues emerged as a major barrier to culturally and linguistically diverse clients’ utilisation of services, understanding of information, and interactions with health professionals. Further, language barriers can reinforce the reliance of people experiencing problems in living on their immediate family. These ‘communication difficulties’ are not merely the result of the inability of many service providers to communicate in a language other than English. Carers, community members and mental health practitioners all characterised medical consultation times as being too short to conduct a ‘meaningful conversation’.

This may be particularly pronounced when an interpreter is present.
Some general practitioners reported difficulties working with interpreters, and expressed reservations about their financial cost to their practice. According to community members and carers, whilst interpreters are usually welcome and often necessary, in particularly sensitive situations, such as in the discussion of psychological problems, care must be taken to employ an appropriate interpreter. Trust and confidentiality were raised as issues that may concern people when faced with an interpreter from the same community. Ethno-specific, and bilingual, professionals were described as a vital resource for culturally diverse clients.

Practitioners’ contact with carers
General practitioners are often the first, and sometimes the only, health professionals approached by carers. Many carers regarded general practitioners as especially trusted figures, as they have ongoing contact with families. However, general practitioners were not necessarily aware of the support services available to carers. Of those who were aware, none had followed up as to whether their clients had accessed these services. It was also reported that the short consultation times available with general practitioners operate as a barrier to discussing mental health concerns.

It was noted that people from immigrant communities who are experiencing problems with living tend to seek professional help only after other avenues have been exhausted, or once their problems have become unmanageable. Several mental health practitioners asserted that the stigma associated with ‘mental illness’ contributes to the late presentation or referral of many clients from immigrant communities. The ‘pathways’ people took, before reaching a mental health practitioner were many and varied. Participants reported receiving referrals from other health care providers, and other mainstream service providers (e.g. Centrelink); religious institutions or spiritual centres; indirect, and less formal routes (e.g. adult education classes); and that some clients ‘self referred’.

The practitioners interviewed reported that different practice situations provide different opportunities for contact with carers. Practitioners also differed in their views about the need to see carers. Some practitioners asserted that carers may usefully assist practitioners by describing the client’s ‘problems with living’. Torture and trauma counsellors reported their preference for working with clients and their carers. The participants also agreed that reaching a common understanding of concepts relating to mental health and illness was essential to the development of trust in therapeutic relationships.

Access to support services
The carers interviewed described a number of difficulties in accessing support services. These include the lack of knowledge held by carers about the existence of support services; the belief that caring is exclusively a family responsibility; previous negative experiences in trying to access support; or to support services being perceived as culturally inappropriate or as unable to meet their needs. It was noted that the regionalisation of available services may prevent people from accessing the assistance they might prefer if given the choice. Further, a number of carers reported having to be pro-active in order to receive information about the mental health of their relative. These barriers are perhaps compounded by the fact that many carers reported significant difficulties with the English language.

The participants reported that language barriers and social isolation make it especially difficult for carers from immigrant communities to access support services. It was also noted that the stigma attached to ‘mental illness’ may prevent carers from seeking support, and that, in any case, many services do not have the resources to adequately meet the needs of people with mental health problems and their carers. Further, support services are seldom adequately publicised. However, a number of participants did note that some carers manage to obtain support through migrant resource centres and religious institutions.

Strategies for supporting carers
It was suggested that carers’ utilisation of support services could be improved by increasing the cultural sensitivity and cultural competence of these services, and through the development of partnerships with carers and ethnic communities. Community education was also suggested as a useful strategy, as were various concrete improvements in support services for the ‘mentally ill’.

The participants in the study offered a comprehensive series of suggestions as to the means by which the support available to carers from immigrant communities might be improved:
· Carers need access to education, information and support. It was noted that informed and well-supported carers are vital partners in the process of the early identification of mental health related problems.
·Migrants should be familiarised with the Australian health system.
· Ethnic media, and in particular, ethnic radio, could be used to provide information about mental illness and to reduce stigma through community education.
· The mainstream media need to take on a more significant role in providing culturally accessible information about mental health issues.
· Migrant resource centres, religious institutions and other spiritual centres need to be supported in their provision of support and information about mental health.
· Ethnic clubs and other ethnic organisations need to be provided with the resources to play a more pronounced role in addressing the needs of specific communities.
· Culturally and linguistically appropriate information should be made available from general practices.
· More information should be provided in languages other than English and both government and non-government sectors should become involved in the provision of information about mental health, and mental health promotion.
· Language-specific support groups should be formed within existing support organisations.
· There is a need for more bilingual practitioners and culturally competent workers within the mental health system, as it is the language skills of practitioners, and their cultural competency, rather than their status as a member of their client’s ethnic community, that enable ‘culturally appropriate’ support.
· Training in cultural competency could serve to reduce the incidence of cultural stereotyping and racism that may occur when practitioners are faced with clients from an unfamiliar culture.
· Clients from immigrant communities should be encouraged to provide input for the planning and evaluation of mental health and support services.

Conclusion
These results clearly demonstrate that carers from culturally and linguistically diverse communities face a particular series of challenges. They are subject to the barriers typically encountered by the unpaid full-time carers of people diagnosed with a ‘mental illness’ (e.g., Morse & Messimeri-Kianidis, 1997). That is, the carers interviewed experience social isolation, financial burdens, and describe themselves as being stressed and tired. However, for carers from immigrant communities, these barriers are compounded by a number of factors. ‘Mental illness’ is particularly stigmatised across culturally diverse communities. As the carers themselves attest, this makes it especially difficult to seek external help, for fear of a negative reaction from the community. Caring is also often regarded as exclusively a family responsibility, thus discouraging access to external agencies. Communication difficulties and short consultation times make it difficult for carers to have their support needs heard, and cultural insensitivity on the part of health and mental health professionals can make negotiations with an unfamiliar health system particularly trying. In practice, the support and information needs of carers from immigrant communities are not being effectively addressed.

The recommendations contained in the full report of this investigation are based on the issues most frequently identified by the carers, community members, and health and mental health practitioners who participated in this study. Many of these are designed to enhance carers’ awareness and utilisation of support services. A number of general recommendations are also presented. These general recommendations provide for the beginnings of a broad, policy-based, support structure for sustainable programs for carers. As many participants pointed out, structural changes are necessary in order to address the complex needs of carers from immigrant communities.

REFERENCES
Gilmore, L. (2000) Survey results. Warning – caring is a health hazard. Synergy, Summer 2000, 13-14.
Kokanovic, R., Petersen, A., Mitchell, V. & Hansen, S. (2000) Care-giving and the Social
Construction of ‘Mental Illness’ in Immigrant Communities. Eastern Perth Public and Community Health Unit and Murdoch University, Perth, W.A. Available online http://www.rph.wa.gov.au/hpnetwork
Morse, C. and Messimeri-Kianidis, V. (1997) Keeping it in the Family: the Health and Social Experiences of Carers in Australian-Greek Families, Department of Immigration and Multicultural Affairs Document and Production Unit, Canberra.

A full account of this study is available online, at www.rph.wa.gov.au/hpnetwork
For further information, please contact Renata Kokanovic Renata.Kokanovic@health.wa.gov.au