Enabling diverse participation
When working to improve the safety and quality of services, we need to think and act in ways that are inclusive and consider diversity. Traditionally, mental health services have been designed along the model of the medical ward or community clinic. Services can make assumptions about the culture, language, gender, age, abilities and identity preferences of people accessing the service.
For example, mis-gendering occurs when a person is spoken to or described using words and phrases that do not accord with their gender identity. These assumptions can negatively affect a person’s current and future engagement with the service or service provider and may result in distress and shame.5
Assumptions around culture and family decision-making can occur when treatment teams work only with the individual consumer or their partner. Often, important family or kin perspectives are not included in decision-making, which affects the family’s understanding of, and commitment to, engaging with treatment processes. And conversely, someone from a culturally diverse background may not necessarily choose for their family to be involved.
Our services have got to be well connected to the grassroots; to be about our communities. And do their job properly and look after people.
There is a challenge as often you are relating to the lived experience of the articulate. Consider the most vulnerable who don’t have opportunities. Do we hear those who are quiet such as homeless people, those in child protection, or prison? Or are only the bigger voices heard?
From a diversity perspective, services must be alert to the barriers to good safety and quality of services for everyone; they must develop effective responses to these barriers. This can genuinely happen only by ensuring that various community groups are central in service design and planning.
Diverse age groups
Key issues affect consumers, families and kinship groups in all age groups. For children and young people and their families, timely access to services is critical for families coping with the early onset of mental distress and symptoms. Engaging with children and their families is an important but often neglected part of engagement policies for safety and quality. Particular issues and specific approaches are required. Medicine use, continuity of care, and supported timely transition into adult services are important safety and quality issues. Appropriate responses and follow-up for young people and families experiencing a suicide crisis are a priority. Service access and quality issues are also important for young people who have experienced early childhood trauma, and for young people in contact with the youth justice system. There are numerous strategies for engaging children and young people in organisational decision-making.6 However, another layer of complexity is added because permission is required from a parent or guardian for children and young people under 18 years—particularly when discussing topics such as suicide or trauma.
Older people can experience similar issues in terms of transition to Older People’s Mental Health services for people living with long-term illness. Older people experiencing depression related to ageing and chronic illness, or those experiencing dementia, may need to access services for the first time in their lives. Often older people have complex mental and physical health needs, and care may occur across the health and aged care sectors. Issues also arise regarding medicine use, information about treatment, access to treatment, and exposure to experiences that lack dignity and respect. These are all key safety and quality issues.7
Aboriginal and Torres Strait Islander people
Aboriginal and Torres Strait Islander people have their own ways of understanding mental health lived experience. Aspects of cultural identity, collective experience and lived experience of trauma and distress and service use inform how the experience is understood and expressed.8
Also, the framework of social and emotional wellbeing developed from Aboriginal and Torres Strait Islander perspectives differs from the concept of mental health in Western culture, which means many people have a unique service context. For example, you may be getting help from traditional and contemporary healing, wellbeing services from an Aboriginal Community Controlled Health Service, and primary care and public mental health services.
The setting of consumer or carer leadership in service decision-making also overlaps with other areas of health and community leadership. There may be cultural protocols and kinship preferences that affect whether you can take on the role of consumer adviser, representative or peer worker within a service.
High-quality services and actions to prevent suicide are a priority for Australia. This guide integrates many of the ideas and practices relevant to our national priorities for improvement. These key concepts and policy documents have informed the guide:
- • The social and emotional wellbeing framework.9
- • Trauma-competent and healing-focused practice.10
- • The Gayaa Dhuwi (Proud Spirit) Declaration.11
- • Cultural safety principles and practices.12
- • The framework of cultural respect.13
- • Aboriginal and Torres Strait Islander health leadership and workforce development.
- • Culturally responsive assessment and treatment. practices.
- • Frameworks for respectful community engagement.
- • Integration of National Safety and Quality Health Standards.14
Cultural safety principles
Cultural safety principles originated in New Zealand and have been widely adopted in Australia. They are particularly prominent in Aboriginal and Torres Strait Islander health and in nursing. There are five key principles15 that are focused on health professional values, practices and organisations:
- 1) Reflect on practice
- • Reflect on assumptions of your own identity, health, illness and people.
- • Include your own and other’s definitions of health.
- 2) Seek to minimise power differentials
- • Focus on power differentials between self and consumers and kinship groups.
- • Understand how biomedical dominance may be experienced as unsafe care by consumer, carers, family and kinship groups.
- • Reflect on colonial histories and the power invested in healthcare professions.
- 3) Talk, ask, engage in dialogue with people
- • Understand unique needs, beliefs, understandings and preferences.
- • Understand that safety and comfort are defined by the person.
- • Engage, listen and grow awareness of Aboriginal health systems.
- 4) Undertake decolonisation processes
- • Create spaces that recognise and enable expression of culture and identity.
- • Avoid reinforcing practices that work from unexplored assumptions and values.
- 5) Do not diminish, demean or disempower people
- • Reflect on the outcomes of your actions for others.
- • Ask: what are the person’s or group’s experiences of the interactions?
Culturally and linguistically diverse communities
Many people from culturally and linguistically diverse communities experience difficulties in accessing mental health care. Key safety and quality issues relate to the nature of communication and shared understanding among consumers, families and clinicians. Language barriers and cultural misunderstandings can cause issues in diagnosis, understanding treatment and involvement in care. Education to reduce stigma and improve access to care remain important areas for development.16 Recognition is required of the significant legal-, settlement- and trauma-related stresses facing asylum seekers and refugees. These issues compound distress and influence the experience of mental health problems.
Engagement and partnership strategies must be suitable and comfortable for people, and connect with bilingual workers. Effective strategies include visiting established groups and networks within communities, planning specific events with community groups, and linking with welfare or culturally representative organisations. Developing a mental health workforce with bilingual skills is also a key goal.17
Lesbian, gay, bisexual, transgender, intersex, queer + communities
Members of LGBTIQ+ groups experience higher rates of mental health challenges, including psychological distress, depression and suicide-related crisis. Recognition, acceptance and inclusion are vital experiences that enable people to access services with a sense of safety and trust, and are key actions and areas of development.
The general mental health sector does not yet have the effective awareness and partnerships that exist in the LGBTIQ+ and youth health areas. Services should engage with and support LGBTIQ+ community, advocacy and service networks.18 These partnerships should enable shared learning and organisational development on policies and commitments to safe, non-discriminatory care for LGBTIQ+ people, which includes the use of inclusive language in services’ forms and practices.19, 20 Policies should also promote service partnerships and referral networks with specific programs for LGBTIQ+ youth, adults and older people, including those in rural, regional and remote communities.
Rural and remote communities
As in many communities, for rural, regional and remote consumers and carers, issues around mental health safety and quality relate to accessing help, as well as the quality of help people receive once they are in the service. Quality of care can depend on the knowledge and skills regarding mental health of local general practitioners and hospitals. Generally, rural Australians lack choice in their preferred mental health professionals and services.
Community mental health teams play a critical role in providing advice and coordination of care for consumers, families and kinship networks. Aboriginal Community Controlled Health Services also provide local clinical care, and support people to attend wellbeing services and traditional healers. Where telecommunication infrastructure permits, telemedicine and video conferencing may enable people to access medical treatment. In addition, peer networks and peer workers are becoming available in regional cities. Suicide prevention networks are working to develop referral pathways and improve community awareness and supports for people experiencing crisis.
Rural Primary Health Networks (PHNs) play a key role in bringing people together to discuss mental health needs and create service networks. The commissioning role of PHNs means that consumers and community leaders can partner to identify the types of services that are required, and the criteria to evaluate the services. Consumers, family and kinship groups can also participate in consultation and decision-making forums within public health services operating across regional areas.21
Challenges facing consumer and carer engagement in rural areas include transport and distance, telecommunication limitations, funding to support engagement and travel of people with lived experience, and consumers’ and carers’ of loss of privacy and stigmatisation, and that complaints may influence future care.
Very few carers want to be involved – they are too busy and don’t want to rock the boat. As a small community there is no choice in services as there is only one hospital.
People with disability
Many people using public mental health services live with other forms of disability. This includes people with intellectual disability, neuro-diverse people and people with sensory impairments. Successful communication and access to care depends on the skills, knowledge and awareness of clinicians, so that care can be informed by, and respond to, preferences and needs. Services need to prioritise accessibility and inclusive language. In addition, public services for mental health and disability support must be well coordinated to ensure good communication and easy transition between services.
On the governance level, engagement practices and strategies must focus on access and recognition—ways of empowering diverse voices and supporting people to enter the peer and clinical workforces. Many advocacy organisations and groups promote awareness of preferred practices.22-24