There is a long history of interest in transcultural mental health in Victoria, with the work of Jerzy Krupinski and his group at the Mental Health Research Institute from the 1960s on the mental health of immigrants, and Ivor Jones and others from the 1970s on the mental health of Aboriginal communities. In 1983 Harry Minas had published in the Medical Journal of Australia the results of a study examining the relative rates of use of ECT in the treatment of Australian-born and immigrant patients. A number of such studies demonstrated that there was considerable variation in the prevalence of mental disorders in different immigrant groups, and that there were substantial problems in the diagnosis and treatment of mental disorders in patients of immigrant background.

The international epidemiological work done by Norman Sartorius, Assen Jablensky and their colleagues at WHO and the anthropologically informed work of Arthur Kleinman had a substantial influence on the development of transcultural psychiatry in Australia. The Italian movement of di-intitutionalisation and attention to the rights of people with mental illness, known as Psichiatria Democratica, found expression in Australia with establishment in 1983 of the first specialised Australian transcultural mental health centre in Perth by Gianfranco Boranga and his colleagues. This pioneering centre was joined in 1989 by the Victorian Transcultural Psychiatry Unit (VTPU) and subsequently by the Transcultural Mental Health Centre in New South Wales and the Queensland Transcultural Mental Health Centre.

The VTPU commenced developing its program of work at the Royal Park Psychiatric Hospital but very soon moved out of the hospital to a community setting - a delightful terrace house in Fitzroy. Although the main emphasis in the beginning was direct clinical services in the language of the patients referred to the Unit (four psychiatrists - from Italy, Turkey, Yugoslavia and Vietnam - who had been recruited by the then Office of Psychiatric Services joined the staff of the Unit), the proposal to establish the VTPU emphasised the need to integrate clinical work with a program of work in the areas of policy and service innovation, research and education. The key issue was the development of a comprehensive and integrated capacity to respond to cultural and linguistic diversity. It was recognised at the beginning that research and education would underpin developments in policy and clinical practice.

Early education initiatives
The VTPU has contributed to psychiatric registrars’ training, and undergraduate and postgraduate medical courses on a regular basis since the inception of the Unit. Most regular postgraduate teaching was incorporated into the subject of Social Psychiatry within the Master of Psychological Medicine degree. During the early 90’s a series of lectures on transcultural topics was delivered to mental health professionals on an informal basis. This program was to become the forerunner to the formal award course developed in late 1995 and delivered from 1996 to the present as a Graduate Diploma of Mental Health Sciences (Transcultural Mental Health), under the imprimatur of theUniversity of Melbourne and taught within the Department of Psychiatry.

These early beginnings laid the foundation for a growth in program development and delivery which currently reaches beyond the medical profession to a range of health and welfare practitioners including those in psychology, counselling, occupational therapy, psychiatric disability support and employment, psychiatric nursing, health administration, physiotherapy, education and student support.

Professional development brief
Currently the VTPU is required to design and deliver professional development in the form of short training sessions for area mental health staff. These are usually for a minimum of three hours in duration, but are often designed for a whole day’s input, or on rare occasions, a two-day program. Mostly they are delivered on site so that attendance of as many people as possible is made easy. What began as a requirement to deliver a total of seven full days over a whole year has increased to a capacity amount of eighty full days a year. This of course has required a changed strategy which includes producing a timetable of available blocks for teaching sessions made available to AMHS managers for bookings early in each year.

Topic scope
The scope of transcultural mental health topics has increased over time to reflect the varying needs and perspectives of area mental health services across adult, elderly, child and adolescent focuses. Topics range from the more general and abstract like the relationship of culture and mental health, culturally sensitive practice, cultural and religious values systems, migration, and explanatory models of illness to the more specialised which pay attention to matters of gender, age, cross-cultural communication, counselling, child rearing practices , carer and consumer perspectives, and working with interpreters. Some of the most recently developed topics include the cultural construction of sexuality, second generation mental health, the welfare and mental health of international students, holocaust survivors and ageing, and vicarious traumatisation of staff.

Topics are developed after conducting a needs analysis on a particular area mental health service or agency and the relevant catchment population. This process then is followed by careful attention to the evaluation received from participants after each session which assists in the refinement and development of further programs on similar topics and for similar or different audiences. Topics are available as discrete subject modules to be assembled in varying configurations to best suit each audience.

Collaboration on indigenous mental health education
As the cultural diversity of all minority groups within the Australian population is vital in an inclusive transcultural understanding of mental health and illness, the VTPU has responded to requests from practitioners to include indigenous mental health issues within the programs. These sections have been developed and delivered in close collaboration with the Resource Unit for Indigenous Mental Health, Education and Research (RUIMHER), under the auspices of the University of Melbourne. Participant response has been very positive as many report that their professional education about issues affecting their indigenous clientele has been largely non-existent. A model for a combined indigenous and non-indigenous delivery of training programs resulting from this part of the program has attracted considerable attention nationally and internationally. It is also seen as a practical contribution to reconciliation activity under the health and welfare umbrella.

The ‘awareness, knowledge and skills’ model
Paul Pedersen’s model developed in USA in 1994 as a response to the need for multicultural training of counsellors has been very effectively used in Victorian AMHS settings. The model is based on a combination of affective and cognitive learning strategies which may lead to attitudinal change as well as knowledge and skill acquisition.

Practitioners need to understand the nature of the basic building blocks of the transcultural paradigm, firstly the awareness that healer and patient, practitioner and client, are part of the same equation in that the cultural values of both parties are an integral part of understanding the interaction and relationship to best advantage.

This is essentially a different approach to traditional medical teaching where the practitioner’s cultural perspectives are not a focus or part of the teaching content. For many practitioners, this focus is a new and challenging one to grasp, but once explored and connected to their own fields of work, it develops meaning and legitimacy .

This is followed by knowledge about significant details or events important in minority group history and experience, e.g. refugee and indigenous experience of displacement and loss, major world events that have caused people to migrate or flee their country of origin, or the range of causes - natural, psychological and supernatural - to which people attribute illness. Participants are alerted to expect the experience of an on-going learning curve that will help them to accumulate relevant cultural knowledge from their clients during the course of their active professional practice, and to be comfortable with the ad hoc nature of this type of knowledge acquisition.

The third part of the model - skills - refers to specific tools needed for everyday work with patients or clients from an increasing number of ethnic minorities: e.g. working with interpreters, performing a cultural assessment, verbal and non-verbal communicating cross-culturally , and repairing misunderstanding when things go wrong.

Professional development
Clinicians of all health disciplines need to have the opportunity to revitalise their approaches to their interactions with patients or clients, whatever their cultural origins. There is much ongoing anecdotal evidence of the problems experienced by clinicians when there is cultural distance between themselves and their clients. They report feelings of frustration, inadequacy and bewilderment in terms of carrying out assessment, diagnosis and treatment when cultural issues add an unknown dimension to standard precepts laid down in professional training.

In order to accommodate the requirements of a range of mental health practitioner roles, the VTPU conducted a series of needs analyses not only for content as mentioned above but also of teaching mode of delivery . As the education of mainstream mental health professionals is a challenging and dynamic field, it was important to find a useful teaching style that would make the best use of the short time available to most busy practitioners. It was indicated to the educators that there is a need for an interactive approach which encourages course participants to examine their own professional cultures as well as ethnic cultural background in order to appreciate their impact on a multicultural clientele where expectations and behaviours are not always clearly understood. This concept is frequently a new and different one for the mainstream practitioner who is used to examining only client or patient issues, and not service provider ones.

Postgraduate education initiatives
The VTPU has made a contribution to transcultural mental health at different levels of postgraduate education. This implies an expertise in the field of cross-cultural methodology and analysis, which has been consolidated under the leadership of Steven Klimidis.Over the eleven years of VTPU operation, a total of fourteen PhD, doctoral and research Masters students have worked on significant projects supervised by VTPU staff. Areas of investigation range over the following broad topics of migration and the adjustment process, the relationship of culture and psychopathology, and culturally appropriate services. Some of the cohorts researched include Chinese-Australian elderly, Polish elderly, Hong Kong and Australian elderly, Malaysian parents and children, NESB patients, South African adolescents, and urban and regional Australian indigenous communities.

In 1996, the VTPU launched the first Graduate Diploma in Mental Health Sciences (Transcultural Mental Health). This course was aimed at students from a range of professional backgrounds working in the area of mental health and associated disciplines, including psychiatry, general medicine, psychology, occupational therapy, psychiatric nursing, social work and counselling. For the next five years, some forty students completed selected units or the whole course in part time or full time mode. This has provided them with a solid basis in migration, refugee and indigenous issues, epidemiological studies, cross-cultural assessment and treatment, the relationship of culture and health, and the complementary areas of social policy, service delivery and cross-cultural research and evaluation. Each completing student has been required to produce a 10,000 word thesis based on original cross-cultural research in conceptual, qualitative or quantitative modes. Many students were inspired to choose research in their own area of work or ethnic group. A range of topics of great usefulness and transcultural interest have included aspects of the following: Vietnamese elderly attitudes to changing family dynamics; service development for increasing indigenous access; practitioner attitudes and knowledge regarding indigenous mental health; the place of religion in relation to schizophrenia; mental health promotion for NESB people; transcultural nursing curriculum content; transcultural training needs of mental health staff; potential risk factors for immigrant adolescent psychopathology; support services programs ; service development for the Deaf community; and, Bosnian community attitudes regarding sexual assault.

Future initiatives in professional education
We continue to receive requests for the delivery of distance education programs. In order to fulfil the needs of practitioners both on-shore and off-shore, the next logical step will be to develop and implement on-line programs using computer and internet based technology , not only to serve people far away from Melbourne but also to make on-going professional development available at any time in a busy work schedule at the convenience of the learner. Other advantages to a new on-line teaching mode would include the ability for learners far away from each other to engage in dialogue and collaborative projects on subjects of mutual interest and benefit.

With Australian Transcultural Mental Health Network support , we have begun the exacting - and exciting- task of transferring material from our face-to-face teaching program to the new world of cyberspace, where different educational strategies will be engaged to match the developments in the technology available. The use of e-mail will play a prominent part in instructing, discussing, assessing, and socialising the learning cohort. It is expected that a professional development program may begin with a ‘public’ level of accessible material, which will then be available at ‘deeper’ and more complex award course levels, be they graduate certificate, graduate diploma and master’s degree levels.

Communities, consumers and carers
The VTPU has always been interested in community education and the perspectives of carers and consumers. We have developed models for community education about mental health by using interpreters with language specific groups. This has been piloted with Horn of Africa and Lebanese women’s welfare groups. On each occasion there has been great enthusiasm for the sessions, and a very strong interest and commitment to learning more about vital aspects of health in Australia which may improve the lives of those in their community needing help.

Another model we have tried out involves supporting the teaching and information giving initiatives of a pan-African group who are interested in bridging the gap between mainstream health providers and African communites. This model is really an extension of a ‘train the trainer’ program, which we have developed and delivered to health personnel who wish to train their colleagues in transcultural concepts and techniques.

Both the above models have great potential for reaching out to all culturally diverse groups at all levels of acculturation and literacy. It now behoves us to find the resources to promote, develop and deliver programs of these types to all groups who would benefit from them. In addition we need to address the specific needs of carers and consumers by approaching this within the context of their own ethnic communities. To this end we have begun dialogue with psychiatric disability support groups whose outreach work will inform this process, and with whom we will work collaboratively.

What have we been able to deliver so far?
So far we have delivered a variety of relevant topics at a range of levels to health and welfare practitioners. We now need to extend the programs to include a greater range of directly applicable clinical topics to enhance the established generic content. The collaborative work with ethnic mental health consultants based in various area mental health services throughout Victoria has been a satisfying and useful activity, and has produced a range of programs for practitioners across all sectors of adult, aged, child and adolescent mental health services. However at the same time we need to focus on the wider community where there is a great need for education about mental health and the support education brings in its wake. This should be extended to include programs with increased community, consumer and carer focus, designed to open up hitherto unknown areas like consumer and carer support, and community education, seen through the eyes and experience of ethnic community members. Until this is achieved the job is only half done.