Pathways for culturally diverse clients with cannabis use and mental health issues

Transcription

1 FINDING THE RIGHT HELP: Pathways for culturally diverse clients with cannabis use and mental health issues Ian Flaherty and Connie Donato-Hunt: The Drug and Alcohol Multicultural Education Centre Anthony Arcuri and John Howard: The National Cannabis Prevention and Information Centre

2 Suggested citation: Flaherty I, Donato-Hunt C, Arcuri A & Howard J Finding the right help: Pathways for culturally diverse clients with cannabis use and mental health issues. DAMEC & NCPIC, Sydney. ISBN: For a copy of the full report or for any enquiries regarding this research contact: The Drug and Alcohol Multicultural Education Centre PO Box 2315 STRAWBERRY HILLS NSW 2012 [email protected] This project was funded by the NSW Health Department and supported by NADA. DAMEC is funded by the NSW Health Department. NCPIC is supported by the Department of Health and Ageing. Project period October 2008 to June Acknowledgements This project was funded by NSW Health, through the NGO Mental Health and Drug and Alcohol Research Grant Program, with this grant being administered by the Network of Alcohol and Drug Agencies (NADA). The authors would especially like to thank the respondents and collaborating organisations for their participation. The authors would also like to thank the following: Feona Cowlin for her valuable assistance in recruitment and interviewing; the members of the project advisory group; NADA and the Mental Health Coordinating Council (MHCC); the New South Wales Population and Health Services Research Ethics Committee; Area Health Services Research Governance Officers; and other management and staff who assisted in the project administration and recruitment processes. Contents 2

3 Contents Introduction... 7 Research question, aims and anticipated outcomes... 8 Literature Review... 9 Co-existence of cannabis use and mental health issues... 9 Access to services for CALD clients with co-existing cannabis use and mental health issues Pathways for CALD communities to specialist services Methodology Ethics approval Literature review The advisory group Interviewing Interview schedule and pilot Recruitment Consent process and recording the interview The interviewers Interpreters, bilingual interviewers and translated materials Transcribing and storing the recorded interview Analysis Sample characteristics Part I - Background to service access Cannabis and co-existing mental health issues Method Results Primary concern Co-existing cannabis dependence and mental health issues Psychosis Paranoia Pathways through drug and alcohol services to mental health help Discussion Aetiological issues Method Results Discussion Cultural and family contexts and attitudes Method Results Discussion Part II - Service access and referral Catalysts for service access Method Results Seizure and Self-harm Negative thought, suicidality and homelessness Police and custody DoCS involvement Breakdown Cognitive side effects Contents 3

4 Discussion Referral pathways and service access Method Results Types of services accessed First service accessed Self-managed change Fragmented versus continuous service experiences Repeat visits to the same service Referral pathways Self referral Family referral Criminal justice system referral Service referral The role of the General Practitioner (GP) Discussion Effective approaches Method Results - Therapeutic methods Medication as largely helpful Healthy alternatives to medication Challenges while taking medication Combined pharmacological and non-pharmacological approaches: Pharmacotherapy s role in coming off a substance Dependence on the prescribed medication The significance of continuing care The role of non-pharmacological approaches The role of mental health diagnoses Skills building and planning Flexibility and sensitivity Results - Interpersonal aspects Empathy Shared knowledge Non-judgmental approaches Group cohesion Discussion Significance of therapeutic language Method Results General familiarity with the language and devices of therapy CBT/AA/NA and self-identity CBT/AA/NA and self-esteem Challenges for therapeutic language and CALD Discussion Part III - Structural issues Organisational and structural issues Method Results Separation of drug and alcohol and mental health services The role of individual workers System interface/access Contents 4

5 Resourcing issues Discussion Implications of accommodating CALD Method Results Language and literacy Working with interpreters Stigma, shame, visibility and confidentiality Food and special treatment Discussion Recommendations and conclusion Recommendations Method Working with clients who have co-existing issues Working with clients from a CALD background Discussion Limitations Conclusion References Introduction Literature review Cannabis use and mental health issues Aetiogolical issues Cultural and family attitudes Catalysts for service access Referral pathways and services access Clients' perspectives of effective approaches Significance of therapeutic language Organisational and structural issues Implications of accommodating CALD Bibliography Appendices Appendix 1a - Site Specific Assessment: A real world example Appendix 1b - Timeline for ethics approvals Appendix 2 - Participant information and consent form Appendix 3a - Advisory group terms of reference Appendix 3b - Advisory group members Appendix 4a - Questions for clients Appendix 4b - Questions for health professionals Appendix 5a - Advertisement for worker participation Appendix 5b - Advertisement for client participation Appendix 6 - Vietnamese translation of the participant information and consent form Appendix 7 - Client service use history Contents 5

6 Introduction Contents 6

7 Introduction Increasingly, the co-existence of mental health and drug use issues has been widely recognised and documented (Hall, 1998; Campbell, 2005). This is particularly true in relation to cannabis use, with chronic cannabis use being significantly associated with mental health issues and disorders and social morbidity for some (Agosti, Nunes & Levin, 2002; Rey et al., 2002; Moore et al., 2007). Professionals across both the drug and alcohol and mental health sectors continue to explore and develop approaches for addressing co-existing issues in order to improve client outcomes and client centred approaches. As the evidence base and guidelines in addressing co-existing issues continues to develop, it is important to also investigate the experiences of special population groups within our communities. Greater understanding in this regard assists in increasing the capacity of services to be inclusive of needs that are specific to these distinctive groups. In Australia s increasingly culturally diverse society this is true for those who come from culturally and linguistically diverse backgrounds. In relation to co-existing mental health and drug use issues, the experiences and pathways of culturally and linguistically diverse (CALD) clients accessing help for these co-existing issues in Australia is unknown. Given the emergent recognition of the prevalence of co-existing issues further understanding is therefore needed in order to more adequately provide effective and appropriate services for this client group. This is particularly pertinent given that the limited research currently available indicates that those from CALD backgrounds are less likely to experience the same level of access to specialist drug and alcohol or mental health services than their Anglo-Australian counterparts. For example, a recent Sydney based study of patients making their first lifetime contact with community or hospital based mental health services suggested that immigrant patients consulted a more restricted range of health professionals than Australian-born patients (Steel et al., 2006). Further, in the drug and alcohol sector clients from CALD backgrounds represent a miniscule proportion of drug and alcohol treatment episodes. Research has shown that problematic drug and alcohol use is lower among CALD communities surveyed compared to the general population (Donato-Hunt et al., 2008). The representativeness of this Sydney-based research is limited however, and, as with general population studies, some harder to reach sub-populations may have greater and more problematic levels of substance use. While problematic drug use may be lower amongst CALD communities, the extremely low proportion of CALD clients captured in the Alcohol and Other Drug Treatment Services National Minimum Data Set (NMDS) suggests that people from CALD background are underrepresented in service access. Specifically, of the closed treatment episodes in in NSW, 87% were for clients born in Australia and 98% were for clients whose preferred language was English (AIWH, 2009). This is particularly concerning given the high cultural diversity of New South Wales population, where, in % were born overseas and 21% spoke a language other than English at home (ABS, 2006). Increasing understanding and the capacity of services to be responsive to the needs and circumstances of individuals, and implementing measures to improve access for those requiring assistance, is therefore pivotal. This research project, therefore, aims to contribute evidence to this end. Introduction 7

8 Research question, aims and anticipated outcomes The focus of this project will be to investigate the experience of clients from CALD backgrounds accessing assistance for co-existing drug use issues (including cannabis) and mental health issues. Specifically, the project will endeavour to answer the following research question: What are the experiences and pathways to specialist mental health and drug and alcohol services for CALD clients with co-existing cannabis use disorders and mental illness? The research explores the avenues people from a CALD background use to access mental health or drug and alcohol services. The degree to which being from a CALD background influences access to specialist care, appropriate assistance, and experiences in receiving assistance will be examined. The research methodology will be primarily qualitative. The aims of the project are to: Examine the dominant constructions of mental illness in NSW in the context of the effects these constructions may have on CALD populations accessing help. Qualitatively investigate the experiences of clients from a CALD background with co-existing drug use issues (including cannabis) and mental health issues in accessing appropriate and specialist care. Examine the pathways to specialist mental health or drug and alcohol services for CALD clients with co-existing drug use issues (including cannabis) and mental health issues. Investigate the degree to which being from a CALD background influences the time and pathways taken to specialist care. Examine levels of engagement by those from a CALD background with mental health and drug and alcohol services, compare these with clients of Anglo-Australian background, and explore any impact this has on individuals and families dealing with co-existing issues. Consequently, the anticipated outcomes of this project are to: Use interviews with clients to map the pathways to alcohol and other drugs (AOD) and mental health treatment for CALD clients with co-existing mental illness and cannabis use issues. Explore the range of experiences of CALD clients in accessing appropriate and timely treatment for co-existing mental illness and cannabis use issues. Identify particular access and equity issues for CALD clients in accessing appropriate and timely treatment for co-existing mental illness and cannabis use issues. Develop recommendations focused on improving access and quality of care for people from a CALD background who have co-existing mental illness and cannabis use issues. Introduction 8

9 Literature Review Co-existence of cannabis use and mental health issues The connections between cannabis use and mental health issues have been well documented. As early as 1857, physicians began to express concern about the possible effects of using cannabis. John Bell, M.D. described the novelty of its effects and its apparent harmlessness, but noted the defective pharmaceutic processes which render its preparations of very different strength, and admixtures of various foreign substances make its effects uncertain (Bell, 1857: 23). Bell also noted the psychoactive effects of cannabis, although not unpleasant, but having its first effects on the intellectual faculties.a gradual loss of power to direct the thoughts (Bell, 1857: 26). While Bell s (1857) examination of the effects of cannabis may have been restricted to the personal, more rigorous later investigation also demonstrated connections between cannabis use and psychosis. Tennant and Groesbeck (1972), for example, ascribed a five-fold increase in psychotic episodes among American soldiers in Europe between 1968 and 1971 to the soldiers cannabis smoking. By the late 1980s, possibly the most convincing study in this domain concluded that, over a fifteen year period, individuals who self-reported consuming cannabis on more than fifty occasions were six times more likely to develop schizophrenia than the general population (Andreasson, Allebeck, Engstrom, Rydberg, 1987). Eleven years later, the connections between schizophrenia and cannabis smoking were further elucidated. In 1998, Hall (1998) concluded that cannabis can cause psychotic-like symptoms while an individual is intoxicated, may lead to cannabis-induced psychosis in people predisposed to the disorder, and affect the clinical course of established schizophrenia. More recently, a study by Campbell (2005) at the University of Sydney revealed that eighty per cent of people who had medication-resistant schizophrenia had used cannabis regularly between the ages of twelve and twenty-one. He warned of a large increase in the reported number of people with schizophrenia due to the delayed effects of cannabis use (Campbell, 2005). The literature does not assert unequivocally however that cannabis smoking causes mental health issues such as schizophrenia. The connections between cannabis use and mental health issues appear to be more complex. Hall reports on the study by Andreasson et al. (1987), that while there does appear to be a dose-response relation between the frequency of cannabis use by the age 18 and a risk of the diagnosis of schizophrenia over the subsequent fifteen years (1998: 1614), it is unlikely that cannabis use caused cases of schizophrenia that would not otherwise have occurred. Are people with schizophrenia therefore ameliorating their symptoms by using cannabis instead of the cannabis use giving rise to the schizophrenic symptoms? Due to the manifold accompanying behavioural and environmental factors, it would be extremely difficult to determine if there is a causative relationship between cannabis use and schizophrenia in the general population (Andreasson et al., 1987; Der, Gupta and Murray, 1990; Linszen, Dingemans and Lenior, 1990; Turner and Tsuang, 1990; Hall, Solowij and Lemon, 1994). However, cannabis use is connected with more adverse affects other than psychotic symptoms. Recent research demonstrates that cannabis use may also have connections with depression and other mood disorders (Rey, Sawer, Raphael, Patton and Lynskey, 2002; Moore et al., 2007). Again, a causative relationship has not been clearly established. It is possible that there are common aetiological factors that produce depression and predict cannabis use (Rey et al. 2002). As with psychotic symptoms, it seems likely that cannabis use may not be the cause for mood disorders, but could be the catalyst for their development (Compton, Grant, Colliver, Glantz and Stinson, 2004; Raphael and Wooding, 2004). Regardless of the lack of convincing evidence for a causative Literature Review 9

10 relationship, the use of cannabis has an association with mental health issues that may be debilitating for the individual as well as the people around them, so painful that they have been known to produce suicidal ideation (Rey and Tennant, 2002; Kalant, 2004), and indeed suicide itself. The prevalence of the use of cannabis and cannabis related treatment entries in Australia is examined every year by the Australian Institute for Health and Welfare (AIHW). According to the National Drug Strategy Household Survey, cannabis was the most widely used illicit substance, by people over the age of fourteen in (AIHW 2008b unpublished: 25). Treatments in publicly funded government and non-government health facilities where cannabis was nominated as the principal drug of concern accounted for 31,980 closed treatment episodes. The AIHW defines a closed treatment episode as: a period of contact between a client and a treatment agency, and: It must have a defined date of commencement and cessation During the period of contact, there must have been no change in: The principal drug of concern The treatment delivery setting The main treatment type. (AIHW, 2008b: 4) The use of cannabis is second only to alcohol as the principal drug of concern, and is the principal illicit drug of concern, when treatment is sought. In New South Wales, for the same period, cannabis was the principal drug of concern in approximately the same proportion of closed treatment episodes as in the national data, 19% and 23% respectively (AIHW: 1). These numbers may not account however for all people who experience difficulties as a result of their cannabis use because of the barriers specific to treatment for cannabis issues. Access to services for CALD clients with co-existing cannabis use and mental health issues The literature on barriers specific to treatment for cannabis issues is scarce (Gates et al.,2008). The available evidence suggests however, that one of the key barriers is that cannabis use is not seen as sufficiently problematic to require treatment (Ellingstad et al., 2006). Ellingstad et al. also identified other barriers to entry to cannabis treatment such as the stigma of being labelled a drug user and the desire to quit without treatment. In their study, other considerations included financial costs, negative feelings about treatment and being unaware of treatment options. Other research has suggested that barriers to cannabis treatment may result from a lack of treatment specific to cannabis (Vendetti et al., 2002) and that some services are often ill-prepared to provide appropriate treatment for cannabis dependence (Gates et al., 2008: 13, from Strike, Urbanoski and Rush, 2003). Strike, Urbanoski and Rush (2003) suggest that treatment providers and researchers need to better understand the relationships between cannabis treatment seeking, motivation to change and potential treatment outcomes (Gates et al., 2008) in order to understand barriers specific to cannabis treatment entry. In addition to the access issues to appropriate health care faced by any individual with co-existing cannabis use and mental health issues, individuals from culturally and linguistically diverse backgrounds must overcome other obstacles. These obstacles may include, but would not be limited to the following: Literature Review 10

11 1. Language difficulties: for individuals whose first language is not English, or if an individual possesses no English language skills, health systems in Australia could potentially be very difficult to negotiate. Access into programs usually requires a level of competence in English. There are relatively few bilingual workers in the drug and alcohol field, and even fewer designated bilingual positions. While some work can be undertaken through the use of interpreters, some treatment programs (such as residential programs) are not well suited to this. CALD clients, especially those from small communities, may doubt interpreters commitment to maintaining confidentiality, or not understand that it is their professional obligation to do so. 2. Social stigma: many authors have identified an increased level of social stigma attached to illicit drug use and mental health issues among CALD communities relative to non-cald communities. Reid, Crofts and Beyer observed that illicit drug use in ethnic communities is often associated with denial, shame, stigma, loss of face within the community, and as a consequence a high level of unwillingness to tell others of personal problems (2001: 14-15). The open admission of illicit drug use and personal problems does not countenance well with many of the traditions of CALD communities (Zane and Kim, 1994; Amodeo, Robb, Peou and Tran, 1996; Fish and Harris, 1997; D Avanzo, 1997; Reid, Crofts and Beyer, 2001). For this reason, illicit drug use and mental health are issues generally dealt with within the extended family unit (Reid, Crofts & Beyer, 2001). 3. The influence of family: as mentioned above, the role of the family in dealing with the issues of illicit drug use and mental health is generally important among CALD communities. The fear of ostracism from the family unit may be very high for younger members of the community, so disclosure of drug problems is greatly reduced (Reid, Crofts, Beyer, 2001). Additionally, among many CALD communities, the needs of the individual are viewed as less significant than the needs of the collective family unit (Reid, Crofts, Beyer, 2001). The importance of maintaining face for the family unit is at the forefront, pressuring the individual into non-disclosure of illicit drug use (Viviani, 1984; Burley, 1990; Ngyuen, 1995; Duong, 1995; Leung and Boehnien, 1996). There is however emerging evidence that some CALD communities are acculturating to the mainstream acceptance of intervention from outside the community (EYIN, 1998; Reid, Crofts and Beyer, 2001). 4. Socio-cultural and economic factors: the approaches to treatment in Australia are largely based upon the Western Ideas of self-disclosure as a pathway to wellness (Reid, Crofts and Beyer, 2001). As a result, among many CALD communities who do not share this view, there is considerable skepticism about the efficacy of such an approach (Major, 1993; Sue, Zane and Young, 1994; McGoldrick, Giordano and Pearse, 1996; Reid, Crofts and Beyer, 2001). Additionally, there may be concurrent stressors that would not apply necessarily to the non- CALD community in the form of pre- and post-migration experiences (Tucker, 1985; Maddahian, Newcomb and Bentler, 1988; Zane, Aoki, Ho, Huang and Jang, 1998; Reid, Crofts and Beyer, 2001). One of the principle purposes of this study is to investigate the possibility that people from CALD backgrounds are less likely to finish treatment and engage in follow-up (Maddox and Desmond, 1996; Van de Wijngart, 1997) due to the cultural irrelevance of many mainstream programmes. 5. Unfamiliarity with processes and pathways: in Australia, approaches to co-existing drug/alcohol and mental health service provision have assumed that mainstream services are Literature Review 11

12 sufficiently inclusive of social and cultural differences (Alcorso, 1990; Romios and Ross, 1993; Dent, Sussman, Ellickson, Brown and Richardson, 1996; Reid, Crofts and Beyer, 2001). However, drug services are often viewed by people from CALD backgrounds as inaccessible (Amodeo, Robb, Peou and Tran, 1997; Samaha, 1997; Pearson and Patel, 1998; Success Works Pty. Ltd., 1998b). The suspicion and apprehension regarding mainstream services is a key obstacle for people from CALD backgrounds, especially in regard to confidentiality (Success Works Pty. Ltd., 1998). For many people from CALD backgrounds, anonymity is foremost when accessing drug and alcohol services (Zaparas, 1988; Everingham and Flaherty, 1995 Johnson and Carroll, 1995). CALD communities therefore, may experience reduced contact with treatment services due to the perception that such services are inaccessible and that cultural imperatives such as confidentiality may not be recognised. 6. Staffing issues: in order for drug/alcohol and mental health services to be effective, service staff must have both an affinity with, and a knowledge of ethno-specific and cultural values and mores of CALD communities (Longshore, Hsieh & Anglin, 1993; Van de Wijngart, 1997; Reid, Crofts and Beyer, 2001). The attitude of service staff must be open and inclusive for services to be successful (Smith and Citta, 1994). Often, the most successful pathways to services will include family and recognise the valued role family plays in producing a positive and lasting outcome (Hatty, 1991; Martin and Zweben, 1993; De Jong, Valentine and Kennedy, 1998; Jacka, Clode, Patterson & Wyman, 1999). A key component of this study is the investigation of staff attitudes towards, and awareness of, the barriers faced by CALD communities when accessing services for co-existing cannabis use and mental health issues. Pathways for CALD communities to specialist services for co- existing cannabis use and metal health issues At present little is known about illicit drug use and CALD communities access to specialist services pathways for mental health disorders. There is a paucity of written material (Reid, Crofts and Beyer, 2001: 16) and readily-available translated materials at key sites where treatment is sought from CALD communities (Success Works Pty. Ltd., 1998). Additionally, among many, the following structural factors affect the pathways to services for people from CALD communities experiencing co-existing cannabis use and mental health issues: 1. Social and cultural factors have a negative impact upon the number and variety of specialist services with which CALD communities engage (Steel, McDonald, Silove, Baumann, Sandford, Herron & Minas, 2006). This in turn may affect the efficacy of the service received (Pirkis, Burgess, Meadows and Dunt, 2001; Steel, Silove, Chey, Baumann, Phan and Phan, 2005). 2. Drug treatments are centred on an Anglo-Saxon model which may not necessarily accord with the beliefs and needs of people form CALD communities (De Leon, Melnick, Schokert and Jainchill, 1993). The format of these treatments has a negative effect on both the attractiveness of, and retention within, the treatment. Ultimately, little is known about the pathways to specialist services for individuals from CALD backgrounds presenting with co-existing cannabis use and mental health issues as there are scant Literature Review 12

13 instances when such a presentation occurs. Furthermore, these presentations have not been routinely and meaningfully documented. In the AIHW report on the minimum data set of closed episodes of drug and alcohol treatments, only 6 percent of the treatments were for people born in a non-english speaking country (AIHW, 2006). The NSW state average for people born in a non- English speaking country is approximately 14 percent (ABS, 2006). The literature suggests that this disparity does not point to a reduced need for mental health services among CALD communities, but rather an under-utilisation of mental health services by CALD communities (Reid, Crofts and Beyer, 2001). Such an under-utilisation is a result of a combination of all of the difficulties of access and cultural and linguistic differences previously discussed (Spathopoulas and Bertram, 1991). The area that has not been sufficiently studied and documented, and the largest gap in the literature, is the experience of people from CALD backgrounds in accessing mental health services for coexisting cannabis use and mental health issues. While causation cannot be reliably determined, connections have been made between cannabis and poor mental health. It also appears that there are inequities of access to mental health services for people from CALD backgrounds relative to people from non-cald backgrounds. This study provides insight into the experiences of CALD populations, and the pathways used to access, and the quality of services for co-existing cannabis use and mental health issues. Literature Review 13

14 Literature Review 14

15 Methodology The aim of the Drug and Alcohol Multicultural Education Centre s (DAMEC) project was to investigate pathways and barriers to specialist service for people from culturally and linguistically diverse (CALD) backgrounds who experience cannabis use and mental health issues. In order to do this, a qualitative methodology was employed in which clients of services as well as workers in these services were interviewed. The interviews were semi-structured and narrative analysis was employed to examine the experiences of these client and workers. Both government and non-government drug and alcohol (AOD) and mental health services in Sydney and the Illawarra were asked to participate. Ethics approval In order to speak to the clients and workers in both government and non-government AOD and mental health services, ethics approval was required. This approval was also required by DAMEC s research policy and as part of the funding agreement in the Non-government Organisation Mental Health and Drug and Alcohol Research Grants Programme. The New South Wales Population and Health Services Research Ethics Committee (NSW P&HSRC) was approached to fulfil this function. This committee is registered with the National Health and Medical Research Council (NHMRC) to ensure that research involving humans is conducted in an ethically acceptable way and in compliance with relevant standards and guidelines. A National Ethics Application Form (NEAF) was completed and forwarded to the NSW P&HSRC. Ethical approval was granted by the New South Wales Population and Health Services Research Ethics Committee (NSW P&HSREC) on 1 st October As amendments to the project plan arose, the NSW P&HSREC was notified, and if necessary formal amendments were requested. The NSW P&HSREC approved the participant information and consent form, worker and client interview schedules, written information promoting the research and posters advertising the research for display in some of the collaborating agencies. There was a variety of experiences in gaining access to area health services (AHSs) sites, and in particular related to timeframes. A significant amount of time in this 18-month project was spent in gaining, or attempting to gain, access to sites with area health services. Specific details for each AHS are as follows: - Sydney South West Area Health Service (SSWAHS): Applications were lodged to three RGOs from the three divisions to conduct research at the main hospitals, mental health units and on-site drug and alcohol facilities for which the RGOs had oversight. In this AHS final approval for Bankstown, Bowral, Camden, Campbelltown, Concord, Fairfield, Liverpool and Royal Prince Alfred hospitals was granted by 23rd February Further requirements required for research within Royal Prince Alfred hospital were unable to be fulfilled given project time constraints, therefore final approval was not granted, and this site was withdrawn from the research. - South Eastern Sydney Illawarra Area Health Service (SESIAHS): Applications were made to RGOs responsible for mental health, drug and alcohol, and community health services in SESIHAS, with one nominated RGO able to process the application on behalf of the other two. Approval to conduct research at nominated sites in this AHS was obtained on 21st October Western Sydney Area Health Service (WSAHS): SSA was submitted to WSAHS. Given project time and resource constraints it was decided not to pursue the further information requested before approval could be granted to conduct research in the AHS as such sites within this AHS were not included in the research. As the real-world example (Appendix 1a) and timeline (Appendix 1b) illustrate, gaining access to these sites comprised a significant amount of time in an 18-month project. Non-government agencies Methodology 15

16 were also asked to participate. Each non-government agency either saw the NSW P&HSREC approval as sufficient, or used their own ethics panel to determine the suitability of this research. Typically, the manager of the non-government organisations approved the research project at their service, with one exception, where the in-house ethics committee was engaged to decide, and approve, the research. Appendix 2 is the Participant Information and Consent Form (PICF) used with non-government services. Area Health Services (AHSs) also required a paragraph detailing who could be contacted within the site regarding the research project. In addition, AHSs PICFs detailed the sites: for example, within SSWAHS, the PICF also had the hospital name such as Concord or Royal Prince Alfred. Literature review A comprehensive literature review was undertaken in order to map the field under investigation in this study. The literature review was conducted searching the electronic databases available at the Universities of Sydney and New South Wales, as well as Macquarie University and the University of Technology, Sydney. The literature derived from these searches was analysed for content relevant to co-existing cannabis use and mental health uses, as well as service access by people from CALD backgrounds with drug use or mental health issues. This content was then synthesised in order to identify possible gaps in the extant literature. These gaps would inform the interview schedules and the analysis of the participants narratives. As the project progressed, and themes common among participants narratives became apparent, further literature searches were undertaken in order to find supporting evidence for additional themes that arose in this study. The advisory group An advisory group was convened for this research project, the aim being to gather expert advice in the fields of drug and alcohol and mental health service provision. The members were people with significant attachment with, and experience in, the drug and alcohol and mental health fields. Among these members, government, non-government and academia were represented. Multicultural health services were also represented. A terms of reference was agreed to at the first meeting (Appendix 3). The group first met in December 2008, and during the course of the project, met five times, with each meeting chaired and minuted by DAMEC research staff. The discussions mainly centred upon the piloting of the interview schedules, service engagement and recruitment, the use and register of language in the report, the themes emerging from the narratives of the participants, and the dissemination of results. Interviewing Interview schedule and pilot The project included two interview schedules, one for clients of services and the other for health professionals working in the drug and alcohol and/or mental health sectors. The rationale for the interview schedules in the current study was based upon the following: Methodology 16

17 Questions utilised in a study undertaken in 1997 by the Drug and Alcohol Multicultural Education Centre (DAMEC) entitled South Eastern Sydney Area Health Alcohol, Tobacco and Other Drug Access and Equity Project Report; Questions utilised in a study undertaken in by DAMEC entitled Working with culturally diverse clients in drug and alcohol services: Worker perspectives, which acknowledged that currently in Australia there is limited substantive evidence on the extent to which cultural and linguistic diversity (CALD) impacts on the receipt of quality care in drug and alcohol (D&A) treatment settings, and; The literature review discussed above. The interview schedules for the current study were then revised according to the recommendations of the advisory group after being tabled at the initial advisory group meeting. The interview schedules were then piloted with five workers and five clients. As a result of the pilot, questions were further amended. These amendments were then forwarded to the NSW P&HSREC for approval as required by the original ethics approval. The piloted interview schedules were approved by the NSW P&HSREC on 4 th August Appendices 4a and 4b are the post-pilot interview schedules for clients and workers. Recruitment There were two parts to the recruitment process in this research, accordant with the recruitment methods for which ethical approval had been granted. The first part was recruitment of health professionals in both government and non-government drug and alcohol (AOD) and mental health services in Sydney and the Illawarra. In most instances, the researchers attended a team meeting of these services and introduced the research project. In order to maintain an ethical stance in relation to the services and the health professionals representing them, the identity of the services and participants has been kept confidential. The workers interviewed, as well as their colleagues, were then asked if they could pass on information regarding the research to their clients for possible participation interviews. Two posters detailing the project were left with the workers, one promoting the research among workers (Appendix 5a) and one promoting the research to clients (Appendix 5b). This promotional material had the consent of NSW P&HSREC. Later in the project, other parts of NSW were included in the research. This amendment was approved by NSW P&HSREC. The second part of the recruitment process involved the recruitment of the clients of drug and alcohol and mental health services. Ethical approval had been granted for arm s-length type recruitment. This process meant that the clients be referred to our research project by the health professionals from whom they were seeking help for their cannabis use and/or mental health issues. When the project was introduced during group settings at residential units, the worker invited all clients attending to participate. The inclusion criteria for the clients were: Diagnosed with co-existing cannabis use and mental health issues; Currently a client of a drug and alcohol or mental health specialist located in regions of NSW. As the project was looking particularly at the experiences of clients from CALD backgrounds, the inclusion of clients who were either born overseas in a non-english speaking country or speak a language other than English (LOTE) at home was emphasised. Clients who were born in Australia and Methodology 17

18 did not speak a LOTE at home were also included for comparative purposes and to further understand the experiences of clients with co-existing issues more generally. These two parts of the recruitment process operated contiguously. In the original ethics application, people who self-identified as having an Aboriginal and/or Torres Strait Islander (ATSI) background were to be excluded. Unintended, four client participants self-identified as having an ATSI background during the course of the interview. An application was made to amend the original project plan in order to include the narratives of these four participants. On 1 st December 2009, the NSW P&HREC declined this amendment and referred the researchers to the Aboriginal Health and Medical Research Council (AHMRC). After much deliberation and given time constraints with five months remaining for the completion of the project, it was decided upon grounds of ethics, that these four narratives were to be excluded from analysis and reporting. Consent process and recording the interview The interviews were typically conducted in quiet, private rooms at the service at which either the client attended or the health professional worked. There were three atypical client interviews, two of which took place in cafés and another in a library. In both these cases, the participants were referred by drug and alcohol workers, and the researchers contacted the participants directly to arrange a time and place to meet. When clients were referred to the DAMEC researchers they had only indicated interest to participate, not formal consent. Upon meeting, the researchers and participants discussed the participant information and consent forms before the commencement of the interview. The participants were then asked whether they consent to participate in the interview, and have their interview transcribed if they agree to it being recorded. The consent form was then signed by both the client and the researcher. The participants were also asked whether they consented to a recording of the interview to be taken, with verbal consent to record the interview given by all participants. Some form of contact details, whether the service, an or postal address was requested in order for the final report to reach the participants. The interview was recorded on a digital voice recorder. At the conclusion of the interview, the participant was thanked for their time, and, if they were a client, were given a thirty dollar voucher from a major supermarket chain. The interviewers Three researchers employed by DAMEC conducted all the interviews. Interviews were conducted May to June 2009 (pilot), and August to December The skill set of the interviewers had a variety of bases, featuring training and experience in drug and alcohol and mental health services provision. Common among the interviewers was training and experience in qualitative investigation in the social sciences. Interpreters, bilingual interviewers and translated materials Funds were allocated in the original project plan for interpreters and bilingual interviewers. Funds were also allocated for translations of the participant information and consent forms. The information and participant consent form for clients was translated into Vietnamese with the prospect of recruiting several participants from a particular service for whom Vietnamese was their preferred language of communication. The translation was undertaken by the Multicultural Health Communication Service who used two translators accredited at professional level by the National Accreditation Authority for Translators and Interpreters (NAATI) (see Appendix 6 for an example of this translation. This Methodology 18

19 appendix is the PICF for clients in South Eastern Sydney Illawarra Area Health Service, Northern Hospital Network. This is the location of the particular service mentioned in this section above). Transcribing and storing the recorded interview Once the researchers were back at their office, the recorded interview was given a unique identifier comprising: participants initials, date and place of recording and interviewer. The recordings were then uploaded onto an external hard drive. These recordings were then de-identified and uploaded to the transcription service via a file transfer protocol. Once transcribed, the interviews were then ed back to the researchers as MS Word documents. These documents were then saved, with the participants unique identifiers, on the external hard drive. Analysis Purposive maximum variation sampling was used to reveal common themes of interest in the experiences of CALD clients of drug and alcohol and mental health services across the variation of services accessed. The project budget allowed for up to 120 interviews to be conducted, with up to 40 interviews in a LOTE, ensuring that data saturation would be achieved, given the range across the multiple themes in both drug and alcohol and mental health under investigation. Given the qualitative nature of the research, data saturation actually occurred after 56 client interviews (four excluded because of self-identification with ATSI, leaving a total of 52), and interviews with 22 workers. Thematic based analysis was conducted, in order to analyse naturally occurring text to discover semantic information and patterns. In addition, the interviewees responses were analysed using Muller s (1999) five over- lapping stages of narrative analysis entering the text (reading and preliminary coding to gain familiarity), interpreting (finding connections in the data through successive readings and reflection), verifying, searching the text and other sources for alternative explanations and confirmatory and disconfirming data), representing (writing up an account of what has been learned) and illustrating (selecting representative quotes) (Greenhalgh et al., 2006: 1175). By using this approach, we were able to gain access not only to the individual narratives but also the wider context framing the participants experiences. From this analysis, we uncovered patterns and inconsistencies that emerged from multiple stories about comparable events (Greenhalgh et al., 2006: 1175). The analysis took place in the following way: 20 of the eligible 52 client transcripts, and 10 of the 22 worker transcripts were analysed by the lead author and a list of emerging themes was defined; The research assistant was given a copy of the emerging themes and then analysed a further three client and worker transcripts (total = 6) according to this list, simultaneously with, but independent of, the lead author analysing the same three transcripts; The lead author and research assistant then compared their independent analyses and found that the material drawn by both researchers from the transcripts aligned very closely; Half of the remaining transcripts were then apportioned to the two researchers for analysis; Methodology 19

20 When analysis was complete, a themes matrix was established using MS Excel. Each theme was given a row and each client a column; The excerpts from the transcripts that were copied out during analysis stage were then hyperlinked to the themes matrix according to theme and client; The significance of the themes and their priorities within the report were then decided in a meeting between three authors of the report; Writing of the report then began using the themes matrix to point to fitting client and worker narratives; Additional analysis took place throughout the writing, especially in relation to points in narratives that were included after the themes matrix analysis. A systematic process of going through each interview to check for additional narratives was engaged, particularly in relation to services access and referral and experiences that related to family and cultural contexts, in order to convey as much of the narrative as possible. As the results and discussion were written up, they were individually reviewed by all authors to ensure consistency of analysis; Clients and workers were de-identified throughout the report by assigning the participants a first and last initial which was not their own. Sample characteristics There were 21 interviews with 22 drug and alcohol and mental health workers, with two drug and alcohol workers interviewed simultaneously. Of these 22, 2 workers came from community centres, 8 came from outpatient drug and alcohol services, and 5 came from inpatient drug and alcohol services. Another 4 workers came from outpatient mental health services and 4 came from inpatient mental health services. Approximately half of the workers came from culturally and linguistically diverse backgrounds. In total workers were recruited from a total of fifteen services, ten non-government and five government services. Of the 56 client participants, 4 self-identified as ATSI and 26 self-identified as CALD, 6 of whom were born in countries defined by the Australian Bureau of Statistics as non- English speaking. The remaining 26 clients did not self-identify as CALD. Clients were recruited from a total of thirteen services, eight non-government and five government services. See Appendix 7 Client Characteristics for further information. Methodology 20

21 Part I Background to service access Prior to examining experiences of service access it is important to first understand the situation and contexts of clients accessing services. The results below present some of the key themes that emerged as participants discussed background issues to their service access. Specifically these include the issues they have sought help for, and the cultural and familial contexts within which they have accessed help. Methodology 21

22 Cannabis and co-existing mental health issues The links between cannabis use and mental health are widely debated (McLaren, Lemon, Robins and Mattick, 2008). In a paper by van Ours and Williams, the common unobserved factors affecting mental health and cannabis consumption (2009: 1) are examined by modelling mental health jointly with the dynamics of cannabis use (2009:1). In their study, van Ours and Williams (2009) found cannabis use and mental health issues to be in many ways linked. In this study, this finding is used as a foundation for examining the effects co-existing cannabis use and mental health issues have had on the experiences of the clients of drug and alcohol and mental health services who participated in this study. In this part of the paper, causative relationships between cannabis use and mental health issues are only discussed in the context of how the clients themselves narrated their experiences of these two issues. In this context, the participants discussed the complexity of the interaction between cannabis use and their mental health and the manifold effects this interaction had had upon their lives and relationships more generally. By examining this context, it is possible to see that the ways in which clients narrate their own experiences of cannabis and co-existing mental health issues may have an impact on their experiences of getting help for these issues. Method The purpose of this part of the paper was to examine how the clients of drug and alcohol and mental health services narrated their experiences of co-existing cannabis and mental health issues. The interview schedule therefore contained the following questions: [Ask if in a mental health service] Have you had any issues with drugs or alcohol? [Ask if in drug and alcohol service] Have you had any issues with mental health? The rationale was that these questions would prompt the participants in thinking about the co-existing issues for which they may not primarily be attending a service, in a drug and alcohol service context for example, cannabis use as well as anxiety. Results The results pertaining to mental health and cannabis use issues are divided by five key themes emerging from the responses of the clients of both drug and alcohol and mental health services. One of the most prominent themes in these was a questioning about which came first the mental health issues, or the cannabis issues. This theme is therefore reported on first, though this does not detract from the significance of the subsequent themes. Here, an acknowledgement is made that the label of mental health issues is ours, and that when asked many clients said they did not have mental health issues, but did experience depression and anxiety, either equating the term mental health issues with diagnosed illness or with more serious mental health issues (schizophrenia for example). WW, for example, was interviewed in an inpatient, hospital-based mental health service and described how she came to be in contact with mental health services for the first time: I went I go to [suburb name] Mental Health cause I tried to commit suicide. And then this is I d have to say two months ago was the first time ever. Yeah. And I didn t have a mental illness. I suffer from chronic depression, but never a mental illness. Yeah. (WW, 2009) Cannabis and co-existing mental health issues 22

23 Primary concern Some of the clients expressed certainty about their experience of mental health issues preceding cannabis use issues. QM for example, a client of an inpatient drug and alcohol rehabilitation service characterises his cannabis use as a way of dealing with pre-existing depression and anxiety and generalises about this to the rest of the population: The reason I think that people develop these mental health issues is that being stoned or high all the time, you re really not dealing with your own thoughts or emotions. Like for me, I was using it [cannabis] to combat depression and anxiety and it just sort of, you don t have your highs and lows emotionally, you just squeeze them down into this narrow band and stay there. You never learn the coping skills to deal with being depressed or being sad or being angry about something. I think that s where a lot of those mental health issues come from, you just don t have the coping skills. (QM, 2009) QM suggests, at least from his experience, that depression and anxiety are a result of not having the coping skills to manage emotional highs and lows, and that the effects of cannabis contributed to this. The complexity of the relationship between cannabis and mental health in QM s experience is evident in his response. On the one hand, he suggests that his depression and anxiety pre-dated his cannabis issues, but on the other, it was in fact the cannabis that prevented him from managing his emotional highs and lows. QM s thoughts about the connections between his mental health and cannabis issues were highly influential in his pathway to seeking help:...it [anxiety] had gotten worse and worse and because I was having more depression I thought I would see a service who could deal not just with the drug aspect but with the mental health aspects as well because my theory was that my drug usage was more related to feeling depressed and my mental health issues. (QM, 2009) In all of this, QM expresses his own feelings about the connections more generally between cannabis and mental health issues: In my experience especially with cannabis, it s a very misunderstood drug... But there s not been from what I can see a real lot of good research or proper peer-reviewed research in terms of cannabis effects and its link with mental health issues. (QM, 2009) By contrast, EF, a client of the same service, squarely positioned cannabis at the foundation of mental health issues: If you put the drug down you really haven t got that problem (EF, 2009). This needs to be contextualised however within the experience EF discusses of his own cannabis issues. EF narrates his experience of being in an inpatient acute mental health facility as a period of clean time : sort of two ways of looking at it, they can highly medicate you and you re just walking around like a zombie all day, or you know, so I wasn t really high, you know highly medicated, I was just eating well and cause I wasn t touching the stuff in there obviously, I walk out alright. It s just basically as soon as you touch the stuff again, boom, you just start, no sleep just the cycle begins again. (EF, 2009) To a degree, there is a paradox in EF s re-telling of his experiences of the connections between substances and his own mental health issues. During one period of staying at an acute mental health facility, EF says that he had been diagnosed as having drug induced psychosis. On the other hand however, EF talks about his reluctance to attend such facilities in the following way: Cannabis and co-existing mental health issues 23

24 You think the psych wards there, are just all spinners in there, you know, just all mental sort of nut jobs, like you don t want to go there. Course there s people in there like that, but for me it wasn t like that, you know I m not nut case. (EF, 2009) It is possible that the complexity of co-existing issues, as seen in the narratives of QM and EF, points to how individuals tell themselves about their experiences with mental health and drug and alcohol issues rather than the connections between mental health and cannabis issues more generally, an issue taken up in the Discussion. Overwhelmingly, the clients discussed in one way or another interactions between their own substance use and mental health issues. Often, this discussion was framed within the context of the interaction of their cannabis and mental health issues and its effect on their experience of getting help. For some the effect was very straightforward. TO, a client of an outpatient drug and alcohol service says, My mental health interferes with my ability to work on my alcohol and drug issues (TO, 2009). In other clients narratives, the substance use and mental health issues, while viewed in some way as connected, are looked at separately in the experience of therapy. EK, a client of an inpatient drug and alcohol service, says: like when I m getting counselling and that for my mental health issues, being depression, anxiety things like this, [long pause] they don t mention the drugs or the alcohol really much at all in connection or anything like that. They try to work out why I m depressed and why I started using in the first place to block out these feelings that I ve had. (EK, 2009) Some clients saw a causal relationship between their drug and alcohol use and mental health issues. UM, a client of an inpatient drug and alcohol service, says: I think there s a real fine line there because using drugs and alcohol can cause you to have mental health issues where you may not have, so that to me would be drug induced or things like that. (UM, 2009) This causality is reflected in the narrative of a client of an outpatient mental health service when he describes his experiences specifically with cannabis and psychotic symptoms. DD says: It s not a diagnosed and treatable, like if I m not using drugs or alcohol I don t feel that I ve got those [psychotic symptoms], I wouldn t feel that I would have had those issues anyway, so I think it s drug induced. (DD, 2009) Depression too, and escape from it, form a large part of the narratives of many of the clients. Some clients expressed the interaction between substance use and depression as very clear in their experience. EP, a client of an outpatient drug and alcohol service, when discussing her substance use issues says, For me, it was mental health first, because of the coming, the depression started very early, the not being able to go out, have friends, I needed the release and that s how I got it (EP, 2009). CM describes his experiences with substances in relation to wanting to ameliorate the effects of his mental health issues: There s got to be a reason why I need to be off my face, I think. Yeah, I suffer a bit from depression and anxiety, but yeah, never really got treatment for it (CM, 2009). At the time of interview, CM was attending an inpatient drug and alcohol service. For another client at the same service, it was the myriad issues he currently faced, including those from the past that had, in his experience, contributed to his current substance issues: Cannabis and co-existing mental health issues 24

25 I think maybe the drugs were suppressing some mental, maybe some mental health issues. I was definitely depressed and stuff at the end because Court was coming up and the way it was affecting mum and dad and stuff. I think yeah, using the drugs more as a blocker, not for them, but for the maybe other issues from ages ago. (CW, 2009) Yet for others, the interaction between mental health and substance use was a cyclical process. DR reflects upon his experiences with a psychiatrist in the following way: Oh, I was using, but that wasn t really why I was seeing him [the psychiatrist], I was seeing him for other reasons, probably the reasons that took me to using (DR, 2009). Echoing QM s comments around coping skills to manage depression and anxiety, NP contextualises her substance issues within a framework of needing to understand her mental health and why she continued to use problematically even in the face of the harms this produced: I was always depressed because I didn t understand why I was doing what I was doing (NP, 2009). Some clients therefore, expressed their experiences of mental health and substance use issues, particularly cannabis, as one clearly preceding the other. In other clients experiences, their mental health issues were expressed as purely the result of substance use, while for others, there were ongoing interactions between their mental health and substance use. One client of an outpatient drug and alcohol service summarises the complexity of all of these experiences in his discussion of his current experiences. HW says: Clearly I m suffering severe depression at the moment. And the last couple of years I was preparing myself to die, and convinced myself it was the right thing to do. So, I wasn t thinking quite logically, and I believe that was influenced by the marijuana. (HW, 2009) When asked for his advice for workers in the field, HW says that effective approaches require the acceptance of mental health workers of the dual disease and to treat both. I believe I probably wouldn t have got clean and sober without some help in that area (HW, 2009). Co-existing cannabis dependenc d ependence and mental health issues All of the client participants in this study spoke about the experience of co-existing substance use and mental health issues, for many the substance is cannabis. Many of the clients described their initiation into cannabis use. Often this was characterised by starting out with small, infrequent doses, eventuating in daily use and dependence. QH describes this process: I think over a period of time it was like a macho thing with the boys and then I got, I was able to be tolerant of it and the more I got tolerant of it the more, I just slowly increased my dosage over a number of years and that s how it, and then before I knew it I developed a habit and then I found myself addicted to it. (QH, 2009) Another client of an inpatient drug and alcohol service expressed how cannabis use had affected his thinking: It s not just a cone; it s like, fuck, that shit will send you back to that routine, back on the spiral, down and down and down you go. And then you won t notice and you ll be like, Fuck I m in this position again. You gotta get out. It s such a head-fuck. Weed, weed is like the, you know how in the 90s, mushroom make-believe; weed is very similar to that. (TM, 2009) Cannabis and co-existing mental health issues 25

26 Another client of the same service described how his cannabis use had affected his experience in accessing a service. ND had been referred by his sister to a hospital drug health service because, as he described, she believed ND had issues associated with cannabis of which he was unaware: when you really need weed and stuff, you don t want to give it up so you don t really think about it. You don t think you have a problem until one day you wake up and shit, you do something that s just like, Shit I really have a big problem. (ND, 2009) UJ, a client of a different inpatient drug and alcohol service, describes how, even when she tried not to use cannabis, the draw of being stoned was too great: I was never straight. I can remember turning around to my girl friend and saying, I d just like to be straight once, just so I could remember what it was like and we went and got stoned (UJ, 2009). UJ discusses this in the context of increasing conflict in the relationship she had with her mother, especially those difficulties that arose from her being stoned. UJ also described the consequences for her of being unable to access cannabis: I remember sitting in the kitchen on the floor crying because I couldn t get any and for 4 years, I ve always been able to get it (UJ, 2009). Other clients spoke about their experiences with cannabis as leading to using other drugs, amphetamines and heroin for example. KW, a client of an inpatient drug and alcohol service, described his experiences with cannabis and other drugs in the following way:...and I found that I couldn t function properly without pot and I d wake up and I d go, I need a cone, and I, and then after taking pot for quite some time, basically I moved on to heavier drugs because pot started to not work for me. (KW, 2009) KW goes on to describe how he began to use methamphetamine and heroin intravenously as a way of masking up and blocking out (KW, 2009) the emotional experiences he had as a result of bullying. He also described the process by which he had come to attend the current service, after going cold turkey from everything but cannabis: the same with marijuana which brought me to the gutter, I brought me, just pushed everyone away from me. I basically was stealing off my parents to pay for my addiction; stealing off friends, family, lying to everyone just to pay for my habit, you know what I mean. (KW, 2009) For other participants however, they saw their cannabis use as leading to other drugs which then brought legal issues. TM, for example, described how he was on bail and one of the conditions was that he attended the inpatient drug and alcohol service at which he was interviewed. He described how on a busy day would smoke fifty cones, but it was his involvement with other drugs that brought him into contact with the justice system: I got into a lot of legal shit, not because of cannabis, I don t think, but cannabis is kind of the gateway, well they say it s the gateway to drugs, it fully is, you know? (TM, 2009 [emphasis ours]). Some of the clients discussed their experiences of sobriety, and how this has affected how they see themselves. EW reflects upon his drug dependence in the following way: Once you remove the drugs and alcohol, I m basically left with myself who hasn t been able to you know live in society on society s rules for well over 20 something years now, so it s a long learning process. (EW, 2009) Cannabis and co-existing mental health issues 26

27 At the time of saying this, EW was drug and alcohol free, but related an extensive history particularly of cannabis as a drug of concern. Similarly, TO framed her drug and alcohol use as a life-long issue, an issue that is present even in sobriety: When you ve used for so long your whole life s revolved around using and you ve got to live a normal life (TO, 2009). Clients spoke too of the attachment to cannabis, and how when entering a service, it was often the one substance from which it was hardest to abstain. KC for example, described his experience in the following way: When I first came here I had about, on about six different drugs. I didn t really give a shit about the other five but the weed, that was like the only stable thing in my life. I d wake up in the morning and it was guaranteed to be weed on me table, that sort of thing. (KC, 2009) This experience is echoed in the experience of GS as he was attempting to abstain from cannabis: Psychosis But the funny thing is I ve come off heroin, I ve come off methadone, I ve come off speed, come off crystal and it s sort of a week later you re fine. With the pot it s not so much your body aching it s your head that runs around and makes it really stressful. (GS, 2009) Many of the clients of both mental health and drug and alcohol services reported their experiences with the effects of psychosis. Connections were often drawn by the clients between these effects and the use of cannabis. OF for example, a client of an inpatient mental health service, made such a connection. When asked why he was admitted to the psychiatric unit of a hospital some years ago, he said, Oh, just from effects of smoking too much pot. Just things like I d watch a movie and think I d be in it and stuff and they d be sending messages to me and stuff like that (OF, 2009). AR, a client of an inpatient drug and alcohol service also reported the effects of psychosis: I was just fucking mad. Yeah, heard voices and I thought there was ghosts in the house, oh, it was just bullshit, the dope was screwing me over you know (AR, 2009). Other clients referred to their experiences as psychotic episodes. DD, a client of an outpatient mental health service, reported his recent experiences in the following way:...last year I had a psychotic episode, I was smoking a lot of weed, I have been smoking a lot of weed for the last 10 years and then I just lost the plot one day, and I thought people were trying to kill me and like usually when you smoke and you wake up the next morning the feeling s gone, like you re like, Oh, it was just the weed but this time it didn t go away, so I was really scared and I thought people were trying to kill me. (DD, 2009) Other clients identified in their experience cannabis use as the cause of their psychosis. BM for example, a client of an inpatient mental health service described the onset of the effects of psychosis in the following way: I only did cannabis I only smoked cannabis three times and the third time and I was I would have been 16 when I did that...yeah, after the third time yeah. I only started smoking when I was 16. (BM, 2009) Another client of the same service reports that while he had a previous diagnosis of schizophrenia, the effects of psychosis have been ameliorated by his current medication: Cannabis and co-existing mental health issues 27

28 I was actually diagnosed with schizophrenia and I had a problem like with hearing things and that s actually gone away now. I m actually I m all better now. I was hearing things back in the past, yeah, so I had a little problem with that. (MW, 2009) AJ, a client of the same service as BM and MW, speaks about the effects of psychosis in relation to how early they were diagnosed, and attributes this earliness with the current positive outcome: I had a I ve got drug psychosis, so but I m a lot better than most of the boys here, so. That s what I ve been told by my doctor. He reckons I m one of the wellest boys here, so I was like, okay, I caught it early. (AJ, 2009) Many of the clients reported the effects of psychosis and many directly linked their cannabis use with effects such as auditory hallucinations. For some, a diagnosis of psychosis helped them in thinking about their experiences with the effects. Paranoia In this section the Oxford English Dictionary definition of paranoia is used (paranoia: noun 1. a mental condition characterised by delusions of persecution, unwarranted jealousy, or exaggerated selfimportance. 2. unjustified suspicion and mistrust of others). This definition is used to avoid conferring on the experiences of the participants associations that may be part of a diagnosis of a paranoid personality disorder, but which did not appear in the narratives of the participants. Paranoia was often matched in the experiences of the clients with other elements of mental health issues, as well as strongly associated with cannabis use. AR reported for example, But the bloody dope you know, it just sent me frickin mad, and full on paranoid and schitzing out (AR, 2009). More than this, AR related his experience of paranoia to his experiences in the service setting, and society more generally: I have huge trust issues, I m even sitting here thinking, are you going to give this to my teachers in there and are they going to read this crap. Are you going to go to the police and you re going to check it out or, you know. I m suspicious of you, you know what I mean, and you re just doing something to help the rest of the bloody community for when they ve got a problem. (AR, 2009) DD reported a visceral experience of paranoia that he described as physical anxiety : [I was] thinking all these paranoid thoughts, and then the other thing was this say, physical anxiety which made it real and I felt like, Whoa, it must, what I m thinking must be true because if it didn t I wouldn t feel this anxiety that I do. So that was tough because I had, it was on two levels, it was like in my brain and it was in my body, so I was, that was tough. (DD, 2009) He elaborates on how the paranoid thoughts were connected with cannabis and how it became for him almost impossible to disentangle his anxiety and paranoia: Like the paranoid I thought, the paranoid thoughts I thought, it s got to be just the weed, but the anxiety that came with it made it real, so I thought maybe it s true, maybe all these things I m thinking are true and what I thought did happen, and maybe they really are trying to kill me and they just haven t found me because I ve moved house every 6 months, and this and that, and it s weird. (DD, 2009) Cannabis and co-existing mental health issues 28

29 Pathways through drug and alcohol services to mental health help Experiences of depression, anxiety and mental health in general featured prominently in the narratives of clients of drug and alcohol services. Some clients described how they perceived the pathways to seeking help for mental health issues as opened by getting help for drug and alcohol issues. EW for example, a client of an inpatient drug and alcohol service, expressed this in the following way: Generally they come in with a drug and alcohol problem, but then all that stuff surfaces for them, obviously their using is burying all that stuff for them and then it starts to come out, I don t know if D&A counselling is sufficient for those guys, it s a very touchy issue. (EW, 2009) For some, this pathway was characterised by lack of mental health services in the past, and coming to a pivotal point with their substance use. NB for example, a client of the same service as EW, describes this in relation to their cannabis and alcohol use: I hadn t really seen anyone for my anxiety and depression because, for years, I didn t even know what was going on, especially with anxiety. I even had one panic attack and I just thought it was like a side effect from the drugs, I was going a bit crazy or something. (NB, 2009) NB goes further to describe how he was also unaware that help was available for his drug and alcohol issues, characterising these as mental health issues: I thought I was just a crazy person, I m just crazy [NB] and that s the way I am, until I got into the rehab. Like even before, I didn t really sort of know that rehabs existed so much, and then the next thing I know I ve got 40 other people just like me. (NB, 2009) Other clients spoke about their experiences with thinking about their mental health issues as a byproduct of getting help with drug and alcohol issues. NB for example, spoke about how he was challenged by the drug and alcohol service to think about his mental health in relation to is substance use: I think it was, the challenge is the change of attitude. To me it was the change of attitude, I had a shithouse attitude towards life in general and I was pretty much, I might put on the happy face, but I was pretty sad inside and sort of couldn t figure out why. And I think the main reason was because I was dependent on drugs and alcohol which made me feel a bit weak. (NB, 2009) A client of another inpatient drug and alcohol service spoke of her experience once she was two weeks into the rehabilitation programme. NP said that she entered the programme feeling on top of the world (NP, 2009), then at the two week point, had the following realisation: I ve just pushed down into the deep dark abyss, I call it. But you don t have to think, you don t have to feel. And when you re really clean and sober they start coming up rearing their ugly little heads [laughs], yeah, that s pretty scary, you get all these emotions and lots of memories, and feelings and stuff, and you re just, Oh my God, you know, I m still dealing with this garbage. (NP, 2009) The experiences then of some of the clients of the drug and alcohol services were characterised by first attending a drug and alcohol service and there starting to get help for their mental health issues. Cannabis and co-existing mental health issues 29

30 Discussion Across the narratives of the clients, the experiences of the interaction between mental health and drug and alcohol use were related in contrasting ways. Some clients for example placed emphasis on depression and anxiety leading to their drug and alcohol use, while others saw the interaction in reverse. Still other clients expressed uncertainty over the nature of the interaction between their mental health and drug and alcohol issues. For many of the clients, their pathway to help for mental health issues was opened up by their attendance at a drug and alcohol service. Other clients of both mental health and drug and alcohol services spoke about their experiences with the effects of psychosis, auditory hallucinations and paranoia among them. Some clients related these effects to their use of cannabis, some clients characterising their use as dependence. These narratives accord with the literature around the contested nature of which issue, substance use or mental health, has temporal primacy (Jané-Llopis and Matytsina, 2006). The narratives in this study also largely support the suggestion that it is typically difficult, for a number of reasons, for clients to disentangle the complex interactions of co-existing issues (Bakken, Landheim and Vaglum, 2003), and that there may indeed be variations in this temporal order (Phillips and Johnson, 2001). In this study this temporal order, at least as expressed by the participants in this study, is acknowledged as complex and multifaceted. Jané-Llopis and Matytsina summarise this in the following way: The population of dual-diagnosed individuals is large and is likely to be heterogeneous in the aetiology of the disorders (Mueser, Drake and Wallach, 1998). Different pathways of causation may coexist at the same time, with different proportions of the co-occurring morbidities being attributable to each other, independent of each other, and some cooccurrence being due to chance. (Rehm et al., 2004) [2006: 532] For people with co-existing drug and alcohol and mental health issues, the two (or more) issues may in fact have developed separately (Watkins et al., 2001). The narratives of the clients in this study reflect the statement by Jané-Llopis and Matytsina (2006). In this study, no clear pattern emerged of whether it was in fact a mental health or substance use issue that brought clients to a range of services. For example, many of the clients of drug and alcohol services reported experiences of depression and anxiety, but that cannabis had in fact brought them to the service. Others reported no mental health issues at the same time as narrating their own depression and anxiety. Further investigation may therefore be warranted in examining outcomes for clients, and how they relate to the clients own narration of their mental health and/or substance issues. For example, what might the influence on outcomes be of the clients understandings of how their co-existing issues intersect? Further investigation here may yield implications for practice more generally, and for co-existing substance use and mental health issues service delivery more specifically. Cannabis and co-existing mental health issues 30

31 Aetiological issues The links between adverse childhood events, sexual and emotional abuse for example, and negative health outcomes in adulthood have been well documented in the literature. Research suggests that adults who have had adverse childhood experiences are much more likely to develop a raft of health issues, among them medical conditions such as cardiovascular disease and obesity (Anda et al., 2006; Douglas et al., Felitti et al., 1998; Springer, Sheridan, Kuo, & Carnes, 2007). Psychiatric disorders, in particular, depression and post-traumatic stress disorder (PTSD) have also been strongly associated with negative childhood experiences (Chapman et al., 2004; Molnar, Buka, & Kessler, 2001; Penza, Heim, & Nemeroff, 2003; Widom, DuMont, & Czaja, 2007). Adverse childhood events are also a demonstrated risk factor for drug and alcohol use and dependence later in life (Dube et al., 2003; Kendler et al., 2000; Nelson et al., 2002). Furthermore, those who have experienced childhood sexual abuse specifically are also at a far greater risk of experiencing major depression, PTSD and alcohol dependence in adulthood (Dinwiddie et al., 2000; Langeland, Draijer, & van den Brink, 2004; Spak, Spak, & Allebeck, 1997). It was therefore anticipated that the participants in this study would identify links between the experience of adverse childhood events and the initiation of drug and alcohol use and the ways in which their AOD use became problematic. What was unanticipated were the key moments in the interviews where these aetiological narratives arose. The depth and breadth of these aetiological narratives, and the differences and similarities within the narratives of the culturally and linguistically diverse participants were revealed at places where it was anticipated the narratives would centre on the basic procedures the clients had experienced in getting help for the AOD and mental health issues. Question Five in the interview schedule asked why people were in various service settings, the responses to which often centred upon extrinsic motivating factors, court or the Magistrates Early Referral Into Treatment (MERIT) programme for example. In many other instances however, the participants produced rich narratives regarding the reasons they were problematically using drugs and the concomitant mental health issues they were experiencing. These narratives are the focus of this section of the report. Method Given the nature of the project, Question Five in the interview schedule (What were you there for? 1 What were you receiving treatment for? ) was intended to elicit from the participants the actual processes which they had been through in their attempts to access a service. The following two quotes illustrate the ways in which the more compact descriptions diverge from the broader aetiological narratives that were more commonly derived from asking Question Five. It was anticipated that most participants may have responded to Question Five in the following way: Yeah, I had a bit of a breakdown. I was selling a lot of drugs and the stress from that got too much, the life that went along with that got too much and my girlfriend got locked up all within - you know, the space of about 2 months all these things happened, so yeah that made me think I needed treatment again and, yeah, did what I thought would work and rang up the detox. (CM, 2009) 1 In a drug and alcohol or mental health service. Aetiological issues 31

32 The aim was to elicit as explicitly as possible the pathways to treatment settings for people with cannabis issues who have co-existing mental health issues, as this is as yet not well documented in the literature, especially in New South Wales (NSW). There are some studies that elucidate these pathways for individuals from culturally and linguistically diverse (CALD) backgrounds experiencing mental health issues (Steel et al., 2006), in culturally-specific settings (Blignault et al., 2008), and in other states of Australia (Reid et al., 2001) but scant literature exists regarding the pathways taken by people from CALD backgrounds seeking specialist treatment for co-existing cannabis and mental health issues. While some of the responses did in fact resemble CM s above, many actually referenced adverse childhood experiences as the driver in the participants initiation into problematic drug use, for example: I used to, around about, oh, between 10 and 12 I used to cut myself a lot, not because of wanting attention because I never showed anyone. Pain, I just had so much pain, I just wanted to hurt myself so I could feel a different pain. (AR, 2009) AR then goes on to recount how the self-harm quickly progresses into problematic use of cannabis, eventuating in his first contact with the legal system and consequent progression into treatment. For AR, when thinking of pathways to treatment, the prominence of painful childhood experience does not appear to be overshadowed by the extrinsic motivator, that is, the criminal justice system. Instead, among many similar responses, AR s feeds into the aetiological narratives linking adverse childhood experiences and problematic drug use later in life. These narratives were examined to look for convergences and differences among and between the narratives of CALD and non-cald participants. Results Among all of the responses there were great similarities in the narratives of the participants surrounding their adverse childhood experiences. While the actual contexts of these experiences differed with each individual participant, the ways in which the pain from these experiences was framed linked almost all of the experiences: these adverse childhood events were horrible memories from which one had to move on (WW, 2009). For KW, for example, problematic drinking was a way of ameliorating the pain of being bullied at school: and now that I ve been in here I realised why I was doing it then; because at boarding school you get bullied 24/7, it doesn t leave you and I was drinking to get rid of the pain of being bullied and teased and that s what the school didn t understand. (KW, 2009) Along with the analgesic effect of alcohol, JW also used cannabis problematically to try and forget: bullying is such an emotional thing, you know? It s something that stays with you for the rest of your life, no matter how much you try and get rid of it and that s what I did with marijuana; I tried to block it out, tried to mask it up in you know? And it got to a point where I was going to bed, waking up with five problems, going to bed with 50, you know what I mean; and then I d wake up in the morning and smoke cones to get rid of the 50 problems and then go to bed with 100. And just keep on doing it and it was just a snowball effect that wouldn t go away. (KW, 2009) Aetiological issues 32

33 The influence of parents and care-givers feature prominently in the ways in which the participants frame their adverse childhood experiences; some, such as AR s, obliquely reference a sense of inherited adversity and pain in the way he narrates his own experiences to himself: Child abuse, bloody drugs, prisons, institutionalisation you know, and all these things. What sort of a fucking story is that?...geez he must have had fucked up parents, you know. Geez that s a bad blood line, they must have been convicts, they must have been fucking whackos or something, you know, I don t want that. (AR, 2009) Other participants refer to the drug and alcohol issues of their parents and primary care-givers when describing the adversity they experienced as a child. For example: my dad was a chronic alcoholic. I never lived with my parents until I came to Australia in 1990, I couldn t handle them. So when I came to Australia in 1990 with my mum, because my dad was already here and my brother, I lost everything. I was 10 years old, I didn t know the language, I developed chronic depression which I didn t know what it was at the time, I couldn t speak English, I started at an English school. So my dad was still drinking heavily and we lived in domestic violence for a very long time. (EP, 2009) In addition to the influence of parents and care-givers, many of the participants attributed in large part the drug and alcohol and mental health challenges they now faced to pre-existing psychological conditions, Attention Deficit and Attention Deficit Hyperactivity Disorders (ADD and ADHD) foremost among them. Sometimes, the narratives of parental neglect and abuse and pre-existing psychological conditions were inextricably interwoven: I suffered from ADHD, ODD, CDD and a lot of mental illnesses and basically I was mentally and physically abused as a young kid by my parents (KW, 2009). For other participants, parental and care-giver neglect had led to undiagnosed psychological issues, leading to later-life drug and alcohol and mental health issues. AR, for example, had described his upbringing with parents who themselves had drug and alcohol and mental health issues and the effect this had on their parenting: I m sure if my parents had of been capable of taking me to the doctors at some stage as a young fella they probably would have said I had HADDHA [ADHD] or whatever the bloody hell it is, you know. I still feel sometimes maybe I ve got that (AR, 2009) EP had migrated from a non-english speaking country as a ten year old. She described the difficulties that many participants from CALD backgrounds mentioned: language and communication. EP sees both her social isolation, in part attributable to language barriers, and her vulnerability as elemental to her drug and alcohol-related difficulties: When I came to Australia, I had no friends, didn t know English, so there was no friends, there was nothing. When I did make friends, when I learned English and that, I was never allowed to go out. So, isolated, daydreaming, you know the whole; invent my own little world, which is sad. And then in addiction, what I thought were friends were not really friends, everyone s out for something (EP, 2009) For one participant from a CALD background, the adverse childhood events brought about by the environment and society in which they had spent their formative years influenced heavily their initiation into problematic drug use: Aetiological issues 33

34 I m from a third world country, different, a lot of drug use, pretty violent. Lot of civil war, lot of terrorist attacks. I came here when I was about ten so it was a big cultural change and all the shit I ve seen, I used weed to numb it out, or forget about it. (TM, 2009) Both EP and TM illustrate the risk factors for drug and alcohol and metal health issues that accompany migration from a country where civil unrest is present (Johnson, 1996; Kennedy and Goren, 2007). TM too, represents the narratives of many other participants when he frames his experiences with problematic drug use within therapeutic language: I just have to get it off my chest cause I m carrying a big bottle of all this shit, that I ve just bottled and bottled. And because of the drugs suppressing it, when it comes back, it just springs out. Yeah, I got mechanisms coping with my anger, drug use, and just grieving, which is something I didn t do. I decided you just have to deal with it, you can t avoid it. (TM, 2009) QM also uses a therapeutic discourse (the description of which used for the purposes of this study is the interaction of the Freudian concepts of intellectualisation, transference and trauma) to describe his problematic cannabis use, with his focus resting upon his former lack of technologies in thinking about his own depression and anxieties:...the reason I think that people develop these mental health issues is that being stoned or high all the time, you re really not dealing with your own thoughts or emotions. Like for me, I was using it to combat depression and anxiety and it just sort of, you don t have your highs and lows emotionally, you just squeeze them down into this narrow band and stay there. You never learn the coping skills to deal with being depressed or being sad or being angry about something. I think that s where a lot of those mental health issues come from, you just don t have the coping skills...(qm, 2009) It is significant that these participants situate their analyses of themselves within a therapeutic discourse for two reasons. Firstly, within this discourse, overcoming both the mental health and drug and alcohol issues is contingent upon developing the technologies to manage these issues when they are at their most extreme. As MA notes, without sufficient guidance and support, mental health and drug and alcohol issues are difficult to manage: And a lot of things you just don t know about, cause you don t have, I haven t had the parents to tell me about different things, you gotta learn them yourself and you can learn the wrong things. Which is quite easy. (MA, 2009) Secondly, such therapeutic discourses rely heavily upon the influences of childhood development to frame adulthood experiences. As is seen in the responses of many of the participants, adverse childhood events have contributed significantly to the ways in which they see the reasons for their initiation into problematic drug use. As AR pithily notes, his current drug and alcohol and mental health issues are largely because, I haven t had people care for me (AR, 2009). Discussion The majority of the clients of drug and alcohol and mental health services participating in this study had experienced adverse childhood events, including sexual and emotional abuse, abandonment and the death of close relatives. In the narratives of these participants, it became clear that these adverse childhood events were in most cases still keenly felt as painful. Such a finding accords with the Aetiological issues 34

35 available literature both on the later life effects of adverse childhood events and their influence in shaping drug/alcohol and mental health issues. Novel in this study however is the sites at which these narratives of adverse childhood events arose. In some ways, this points to the influences of therapeutic discourse upon the narration to self of substance and mental health issues. It could be argued that these discourses, and the practices assumed within them, are not merely inductive; that is, therapeutic discourses shape the sociocultural context in which they operate, and as importantly, influence the ways in which an individual thinks they should view themselves. As Michael Guilfoyle notes: Therapeutic discourses in general and therapeutic practices in particular, are not merely products or effects of the sociocultural context, but actively participate in the constitution of that context. They are part of a set of culturally available discourses and practices (which Ingleby [1985] and Rose [1985] have called the psy complex ) that produce and circulate particular accounts of what it means to be a person (2005: ). In accounting for the places at which the pain associated with adverse childhood events was revealed an unpacking of therapeutic discourse could be helpful in elucidating literally and figuratively how the clients came to be at the service, and how they re-tell their experiences while there. It is important therefore to problematise, for the purposes of recommending further investigation, an unquestioning account of therapeutic discourses and their influence in the participants framing of their mental health and drug and alcohol issues. Aetiological issues 35

36 Cultural and family contexts and attitudes Representations of the cultural contexts of drug use have often been ill-conceived. In the most negative light, drug use by minority communities has been pictured either as a way of escaping the reality of disadvantage, or as a means by which to overcome financial disadvantage, or both (Williams, 1990; Harrell and Peterson, 1992; Currie, 1993). As such, the minority drug user is represented as more dangerous, deviant and prone to abuse drugs than his middle-class counterpart, because he is reacting to social pressures that only affect urban ghetto or underclass communities (Covington, 1997: 117). When problematic drug use does affect members of advantaged communities, it is viewed much more as the problem of the individual rather than the community more broadly (Covington, 1997). Such an anomic view (Durkheim, 1951) of the context of drug use in minority communities is starkly at odds with the aims and findings of this study. The literature suggests (Lee, 1996; Ja & Aoki, 1993, D Avanzo, 1997; Samaha,., 1997) that among some culturally and linguistically diverse (CALD) communities, denial and stigma are associated with issues around drug use. Similarly, among some CALD communities, the same fear of ostracism exists in issues related to mental health (Blignault et al., 2008: 186). Part of the aim of this study was to explore the attitudes among CALD communities to help-seeking for co-existing cannabis and mental health issues. Rather than viewing the issues as aggregate (Covington, 1997: 186) within these communities, this study sought to examine the individual experiences of those people who have cannabis use and mental health issues. The aim here was to elucidate the pathways and barriers to treatment for these co-existing issues. To this end, we asked the participants in this study about their and their self-identified communities attitudes toward drug use and mental health, aiming to add to the literature surrounding the significance of cultural and family differences when tailoring services for drug and alcohol mental health issues. Method Question fourteen of the interview schedule for the clients of services participating in this study asked: What is the attitude towards drug and alcohol issues in [your culture]? This question was asked of both the participants who self-identified as having CALD background, and those participants who selfidentified as Anglo-Australian. Question one of the interview schedule asked: What is your cultural background? In response, Anglo-Australian came in several permutations, including uncertainty about exactly constituted cultural background. These permutations included Anglo-Celtic, Aussie, and Aussie, I guess. Due to the large body of literature surrounding stigma and shame around drug use and mental health generally, it might have been assumed that these issues would feature in the narratives of the participants. For example, one of the participants who self-identified as having a CALD background, succinctly stated: There s not a lot of people who do drugs. And if they do drugs, they re outcasts (TM, 2009). Many similar responses came from the clients who did not self-identify as having a CALD background. Often, these responses were related to a perceived lack of understanding in the community more generally of drug and alcohol and mental health issues, and the consequent lack of empathy for people who do experience such issues. When combined, these two perspectives can assist in framing the cultural and family contexts of drug and alcohol and mental health issues. Part of this study was to examine the convergences and differences in these attitudes across and within cultural and linguistic diversity, and highlight the significance of family under these conditions. While positive moves in the direction of accommodating cultural and linguistic diversity have been made, it may still occasionally be observed that an Understanding of the ethnic family Cultural and family contexts and attitudes 36

37 ethos was of pivotal importance but frequently ignored by treatment services, contributing to the exclusion of ethnic communities from appropriate assistance (Reid et al., 2001). Results One of the participants who self-identified as have an Anglo-Australian background illustrated clearly the lack of understanding that appears to exist in the community more generally, and the consequent lack of empathy with people who experience these issues: I think it s really looked down upon, it s sneered upon because it s not understood and if you don t really, if you ve never been in that situation you can t understand it, you know. Like, so people, the straight 180 s, as they like to say, they have no right to look down on anyone else who s got mental health or drug issues because they ve never done it so they don t know why those people do it or why they have that. (EW, 2009) One of the most striking features of the responses of the service clients was that cultural differences and convergences were almost always discussed in the context of the family. So, for instance, comments such as Italians are pretty front-up. Yeah, they re pretty straight forward people (AJ [who self-identifies as having an Italian background], 2009) were infrequent. Often too, the clients, even when they self-identified as having a CALD background, distanced themselves from narratives that specify differential elements of their cultural background. For BR for example, cultural diversity is actually an equalising element in service delivery: Like I said, maybe the nurses could learn a bit more about each person s culture but for the Maori culture there s nothing really that they need to learn (BR, 2009). There is a curious paradox in BR s comments however. While on the one hand, he does not see any particularity in his background, on the other he perceives it as a potential source of discrimination. When commenting on his own background, BR says: I don t think it s made it easier but I don t think it s made it harder either. I think it s just been in the middle Cause I don t really disclose my cultural background so people can t really discriminate against me for it (BR, 2009) BR goes on to describe why this discrimination may take place: A lot of people think like Maoris are tough guys that are going to get on your back and beat you up and stuff like that, when that s not really true, like I mean we re all good people if you get to know us. (BR, 2009) Even though BR describes what he perceives as a persistent and pervasive stereotype of Maoris, he does not seem to feel that his background has had a deleterious effect on his service access or provision. Interestingly, some of the participants transfer issues surrounding their own backgrounds and their effects on service to other, possibly more noticeable groups. For example, AJ, while not perceiving effects on service because of his cultural background, saw a difference in the response to service for a different cultural group: I ve seen different cultures and they tend to you re right, they do tend to stick to their own. Like I remember the Sudanese dude and this other Sudanese dude, who was a kid that come to the drug and alcohol place, and they actually connected a lot better, cause, yeah, it was like, well, that s because he s the same culture and stuff, they actually connect a lot better. (AJ, 2009) Cultural and family contexts and attitudes 37

38 There are many possible reasons for these differently constructed understandings of the effects of culture on service for drug and alcohol and mental health issues, all of which deserve further investigation. For now, we take them to point to the possibility that culture in the context of family is more significant in its effects than culture alone. Reid et al. (2001) extensively discuss the family ethos among what they call ethnic 2 communities, and in particular reference to cultural and institutional barriers to service for drug and alcohol issues. Of special note in the contributions from the participants in this study, both clients and workers, was the magnitude to which this was the case. The impact of the family had a twofold effect: it seemed in many senses to inform the clients perception of their own cultural background, as well as service options. As mentioned above, many of the participants viewed their cultural background as deeply embedded within the context of their family. For example, when thinking about discussing his drug and alcohol and mental health issues with his family, AJ comments that: I don t really talk to them that much, because they re really full-on Italians. I don t know how to explain. It s just like they stick themselves and I stick to myself, so and I don t talk to them very much (AJ, 2009) For AJ it seems, his Italian background is situated almost entirely within the context that he cannot readily discuss his substance and mental health issues with his family, rather than this reluctance or inability situated inherently within the culture. Further, AJ is keen to maintain these family connections, even though they seem perilous at times: I ll talk to a lot of the guys here and their families disown them. I don t want my family to disown me. So, because I ve got Italian in me, that s really like an issue with the family, so I just keep it to my mum. And she said that s fine, so, yeah. So I hope that was all right...(aj, 2009) Again, in many ways, for AJ, cultural background and family are inextricably entwined. In some ways too, some of the participants viewed their family life as one that exemplified a particular cultural background. WW, for example, sees the actions and attitudes of her parents as culturally significant, perhaps more so than the actions and attitudes of two individuals: but my parents are still very Greek. Can I give you an example?...my niece has turned, not 100 per cent Muslim but she s wearing a scarf, she s marrying a Muslim man and they ve disowned her. (WW, 2009) Resounding through many of the participants responses though, including WW s, is the overwhelming importance of the parental figures, and family more generally. For WW, for example, her parents are a source of guidance, even if fairly bluntly: I ve got my parents on my back. And they re not on my back because I m a baby, they re on my back because they love me, they care about me, and they don t want me to go down the wrong way, you know. I ve got beautiful little children. And my mother said to me, Look, you know, I don t understand how you can touch a bottle when you look at these beautiful girls. And if you look at my children, they re beautiful, but I can t tell my mother what my daughter did. So catch 22. (WW, 2009) 2 In 2010, the term culturally and linguistically diverse is more commonly used. Cultural and family contexts and attitudes 38

39 The conundrum for WW is that her daughter had been behaving in a licentious manner, which would have met clear disapproval from her parents. More than approval, however, is needed by some of the participants from their family. For some, contact with their family was elemental to maintaining their mental health: When I first moved in here they kind of kept me from my family for a little bit because they wanted me to live more independently but my family, because it s such a big part of my life, I really struggled without my family. (LH [who self-identified as having a CALD background], 2009) LH s comments point in many ways to dominant models of supported accommodation. LH lives in a group home setting. His housemates also have mental health issues. Fortunately for LH, his contact with his family was maintained: I think because they saw how unwell I was getting without my family, because a family is a big part of my wellbeing (LH, 2009). Where lie, then, the convergences and differences between the narratives of the people who selfidentified as having a CALD background and those who did not? For many of the participants who identified as Anglo-Australian, family, for the larger part, had a reduced impact upon their feelings about drug and alcohol and mental health issues. Many even describe a total alienation from their families, for example: They didn t know their son at all, which is sometimes the way I feel about them. So they haven t been really involved to date but I haven t given them the chance to be either. I only see them two or three times a year. (QM, 2009) While QM expresses a sort of passive familial alienation, other participants who self-identified as having a CALD background expressed a desire not to draw their families into the perceived mire of drug, alcohol and mental health issues: That s what I ve done now, I ve cut off all the good people that live a normal life, I ve cut them off because I don t want to bring them into this world and plus they can t, they don t know how to act in that world. So I d rather just leave them there. I went so deep in that it s a long way back (TM, 2009) Part of the reason TM expresses a desire to keep his family at a distance is associated with what he perceive is the shame of his substance and mental health issues. When discussing a television documentary being made at the treatment site at which he was temporarily resident, TM says:. cause what if one of my parents friends is watching it and go, Oh yeah, we saw your son. Say what? I don t want to bring any more trouble to my parents, let them live their life and just get this over with. I can just be free. I just want my freedom back. (TM, 2009) While intimating optimism, TM s comments cannot belie a sense that his current circumstances are a source of disappointment or pain for his family. This is similar to WW, currently an inpatient in a hospital based mental health ward, who says: My father can t even walk in this place because it would break his heart (WW, 2009). Within TM s narrative, is a tacit reference to the discourses surrounding the migration of people from less advantaged countries to more advantaged countries with the purpose of founding a better life 3 for their children. At least, this is how TM perceived the 3 This point is further elaborated in the Discussion. Cultural and family contexts and attitudes 39

40 actions of his parents: It s almost like I m shitting on the things that my parents had built up, it s not very respectful, but I never bring any trouble on them but it s very difficult (TM, 2009). As TM describes, living in Australia is a large contrast relative to the living in the country in which he spent many of his younger years:.then I d get kicked out or suspended or anything, they d just go mental and try to apply Eastern laws. Back home it s not like you can run away, you run away, someone would probably kidnap you and sell you off. (TM, 2009) Narratives around the importance of making the most of opportunities present in Australia featured prominently in the narratives of the participants who self-identified as having a CALD background and in the narratives of some of workers. Especially in this context, these narratives are subsumed within the framework of family. WW notes, for example: When you talk about my background, you ve got to talk about someone s that s older. Because I m Australianised and, yeah, I was born here, bred here, so it s a bit difficult, but I can answer it for an older point of view. I imagine that they [D&A/mental health workers] need to understand that they re very set in their ways; they re very stubborn and they re very arrogant and that s how they are. And I don t believe it s because they don t know better, I believe because they came here, 1959 and they struggled to be somebody. And they only came here with a suitcase, as in we were born and we were given money from the Government. It s a difference. Okay, they ve struggled. (WW, 2009) As a result of their parents struggle, VW feels bound to overcome her substance and mental health issues, because it was for the reason of providing her with opportunity that her parents migrated to Australia in the first place, or so her narrative suggests. This is a common theme too in the narratives of the workers. The feelings of TM, who came to Australia from a country devastated by civil war, are echoed in the comments of the worker, KW:...you find people from cultural backgrounds where it has been a very traumatic time when the parents came to Australia, they find that with a child doing that [drugs] it s almost like Why did I come here, I m not giving my child a chance to really be better than me. (W:KW, 2009) One point of convergence and difference in the narratives of the CALD and non-cald participants lies somewhere between the ideology of individualism and the collectivism of more traditional societies. One participant states this intersection clearly: Like the Aussies are like, Just stand on your own two feet and you ll get through it and I do that, and then the Chilean side is there to like support and be like you know, If you need help we re here for you, if there s anything, if you re freaking out and you want to call us just give us a call, and we can tell you that it s all bullshit and everything you thought is not real you know, and I was like, Well, that s good, cause I m getting two sides like if I didn t have the Chilean side you know, I probably wouldn t have been able to stand up on my own two feet and feel more scared, or if I didn t have the Aussie side I probably wouldn t of done it on my own, it would of taken me longer to sort of get through it all, you know. (DD, 2009) At this intersection however, there are contrasts in the narratives of the CALD participants, many of which relate to familial attitudes to substance and mental health issues. WW, for example, who comes from a Greek background, says: Cultural and family contexts and attitudes 40

41 And another thing about my parents, I ll give you an example. They say to me, Okay, we know, you know, everyone knows. Let s move on. It doesn t work like that. I need counselling. I need help. It s a process, but with my parents, it s just finish. (WW, 2009) In contrast to the views of their parents, WW refers to a therapeutic discourse. DD draws one of the most salient conclusions when he thinks and speaks about his familial responses to substance use and mental health issues:...my Dad s an Aussie and we were talking about it yesterday, and he thought that it you know, that it was something that I d get over really quickly, he thought you know he said, I thought it would take a couple of months to get over, I thought it was an overnight thing and then I had to explain to him that a mental health isn t, like mental health issues aren t overnight things, they take a long time to get over, like it could take a couple of years to get over. But my Mum and she was, on the Chilean side it was like you know, His brain messed up so it s going to take a while to get over but then that could just be them as a person you know, I mean like them as people, it might not be anything to do with the cultures. (DD, 2009 [emphasis ours]) The cultural contexts of attitudes to drug and alcohol and mental health issues then, become more meaningful when connected and entwined with the context of the family. While there are convergences and differences in the surrounding narratives of the CALD and non-cald participants, questions may also be asked about the role of the individual, both the person with the substance and mental health issues, and the people around them. These questions could potentially lead to an enhanced understanding of the best way forward, cultural background inclusive but notwithstanding, when managing substance use and mental health issues. Discussion There are then many points of convergence and divergence in the narratives of the participants who did and did not self-identify as having a CALD background. Across all the narratives, for example, a feeling of shame associated with drug use became apparent. Divergent however, were the narratives of the non-cald participants when discussing family. Largely, the non-cald participants spoke little about their families when reflecting upon their attitudes to drug use and mental health. For the CALD participants however, narratives of family influences featured prominently. This in many ways accords with the literature, particularly which stresses the importance of at least recognising family in the service delivery drug and alcohol issues (Reid et al., 2001). What is not found in the existing literature however are two key points. Firstly, that, as in the case of TM, those who self-identify as having a CALD background, do not always want to involve their family in accessing services for their drug and alcohol and mental health issues. Secondly, cultural background and family are often heavily intertwined, yet some CALD clients narrate ambivalence regarding the role their cultural background and family have had in relation to getting help for their substance and mental health issues. These two findings point to a number of implications for practice. For example, on the one hand, while recognising the family of the client, and their potential role in service delivery and receipt, on the other, it may be the case that not every CALD client will want to involve their family. In the narratives of the CALD participants in this study this was often because they felt such involvement was in some way disrespectful, or an affront, to the efforts their parents had made more generally, and in particular by migrating to Australia. Further it is possible that cultural background is, in many ways, inseparable from family background. Therefore, this needs to be considered in the context of service delivery, Cultural and family contexts and attitudes 41

42 especially if the client does not want family involvement in the process. Further investigation could here be undertaken. Many implications for practice could be yielded from investigating how the process would look of recognising family as cultural background, even if the client does not want their family involved. Cultural and family contexts and attitudes 42

43 Part II Service access and referral It is amongst this background that the client participants successfully engaged with specialist drug and alcohol or mental health services. As many experienced often long term co-existing issues and preceding adverse childhood experiences, examining the motivating reason or catalyst for initial service engagement was of interest. Further, given the challenges associated with accessing services, it was also seen as important to identify the referral pathways and services accessed for those who had successfully engaged with the health care system, as well as what participants found helpful. The results below present some of the key themes that emerged as participants discussed their service access. Cultural and family contexts and attitudes 43

44 Catalysts for service access In examining the pathways and barriers to help with cannabis and mental health issues for people from culturally and linguistically diverse backgrounds, it is significant to analyse the catalysing event that led to accessing a service. Possible sources of referral to drug and alcohol and mental health services include general practitioners, family and self-referral. In this part of the study, the aim was to examine the events occurring in participants lives at the time at which they first contacted a service for help with their substance use and mental health issues, or if they were compelled to do so, which events had led to this. In this part of the study, the following definition of crisis is used: A vitally important or decisive stage in the progress of anything; a turning-point; also, a state of affairs in which a decisive change for better or worse is imminent; now applied esp. to times of difficulty, insecurity, and suspense in politics or commerce (Oxford English Dictionary, 2009). The aim therefore was to analyse how these catalysing events came about, and if there are ways in which these events can be circumvented in order for the individual to get help before crisis occurs. Further, the aim was to examine how an improved understanding and recognition of crisis may lead to improved services for clients of drug and alcohol and mental health services. Method In order to elicit from the clients details of what was happening in their lives at large, and in particular, regarding substance use and mental health issues, when they first got help, the following questions were asked: Can you remember when you were a client of X service? [Further probes: How old were you when you first went there? How long ago were you there?] What were you there for? What were you receiving treatment for? What were the main reasons you went to service X? What did you want to get out of your time there? Who referred you? Who brought you there? [self referral, doctor, nurse, health care workers, a drug and alcohol counsellor,, telephone helpline services, s, staff at a detox facility, staff at a pharmacy] By asking these questions, it was hoped that the clients would have cause to reflect upon the catalysing event first getting them help, and also getting help on a continuing basis. Results The catalyst for seeking help for drug and alcohol and mental health issues was often characterised by crisis situations. Such crisis moments can be broadly described as failing health, legal issues, and, for many parents who participated in this study, intervention by the New South Wales Department of Community Services (DoCS). Seizure and Self-harm Significant, in the narratives of many of the participants, was the co-occurrence of mental health and substance issues as the catalyst for help-seeking, and annunciated so strongly as such. In the first Catalysts for service access 44

45 instance, for example, the physical effects of substance issues were so severe for some of the participants that help for these issues was not necessarily voluntarily sought. For one participant, AJ, one of the outcomes of their substance use rendered him highly dependent on medical intervention: I started having seizures and it was from using too much drugs, so I was just I was like, Oh, that s enough. I don t like it. My body s obviously rejecting it (AJ, 2009). AJ was not alone in reporting seizures as a result of their substance issues. AR, a client of a residential rehabilitation programme, and who reported a history of substance use that began when he was twelve years old, also reported an involuntary admission to hospital in the following way: I wanted to know what the fuck I was doing in hospital again and they said you re lucky you know, you had three seizures, one went for 11 minutes, one was 7 minutes and the other one was 4 minutes or something. (AR, 2009) There is an element of self-determination on the narrative of AJ that is in many ways absent in the narrative of AR. AR, too, narrated a chilling episode of intentional self-harm which was the catalyst for his current help-seeking experience. AR seemed quite shocked himself when he said, Fuck there was some blood. Yeah, I was dangerous to myself (AR, 2009). This was contextualised in an episode of self-injury in which AR was admitted to Accident and Emergency by ambulance. Negative thought, suici s uicidality and homelessness In many of the narratives of the participants too, medical intervention was compelled, but in a different way because of suicidality. NF, for example, relates the episode in which he had attached a hose to the tailpipe of his car with the view to gassing himself: I got out and had a cigarette and thought about it, the I decided to go and burn all my clothes first and all the books and by that time, I didn t really want to do it, so I sought of made it was sort of kind of a call for help, cause if I wanted to do it and my mum and dad were asleep, so but I sort of made a bit of a ruckus so they wake up, cause I didn t really want to do it. (NF, 2009) In NF s narrative, for example, his family had called the Police as a result of his attempted suicide: I was just sort of crying and upset and then the police came and they said that if I didn t go voluntarily with your parents, we ll have to take you in the paddy wagon, so they just followed us to the hospital and made sure we were there and that stay was for three weeks. (NF, 2009) NF reported to have started smoking cannabis at age thirteen, and had witnessed the suicide of one of his immediate family. Technically, his admission to hospital was of a voluntary nature. For others, however, intervention for their substance use issues was of a less voluntary nature, often associated with having no fixed place of abode. GS, for example, a client of a residential mental health service, reported: I feel depressed and thrown out of my home, that time and I drank too much And on the road I feel a lot less I feel like nothing is here for me so I don t know what trying to do. They ask me, I ring the police I don t know cause I m too much alcohol drink Police took me here. (HS, 2009) Catalysts for service access 45

46 For other participants experiencing homelessness, it was their local networks that provided them with information regarding available help. MA, a client of a large public opioid treatment programme, reported, I found out from other users, whereabouts to go. I was homeless at the time and when you re homeless you get to know everyone around (MA, 2009). Police and custody For EK, a client of a residential rehabilitation programme, being on the streets and police intervention brought him to help: First went to a mental health clinic, the Police took me there when I was drunk one time. Obviously, someone had called them up; I was walking the streets, being a maniac basically. So they took me there (EK, 2009) For others, help for substance issues was compelled while they were already in custody. For TM, help became available as a result of a custodial sentence: Well that actually, it was suggested to me when I was locked up.yeah, in juvenile detention, yeah, yeah. I did have a Drug and Alcohol Counsellor (TM, 2009). Some clients too had been voluntarily admitted to hospitals and then found that they could not leave of their own accord. TO, for instance, reflected, I ve been taken by police; I ve been taken by workers, and then scheduled. I ve gone on my own and then been scheduled (TO, 2009). In all these clients experience, a crisis in their lives had occurred which brought them to help, whether voluntarily or involuntarily. DoCS involvement For many of the participants who were parents, it was DoCS intervention around their children that catalysed their episode of help, sometimes voluntarily and sometimes involuntarily. For many, contact with DoCS was ongoing, but in the responses outlined below, it was the removal of children from the participants custody that largely catalysed their most recent service contact. In narrating the catalyst for BM arriving at the service he was currently attending, it became clear that the return of his children was the motivating factor: DOCS took my kids at Christmas and I was arrested for a couple of charges as well and then it s been a court matter And so I m getting custody of the kids which is pretty cool So I m pretty freaked out, you know, things happen for a reason (BM, 2009) The reason for his rehabilitation, BM sees, is the custody of his children. Similarly, UJ reflects upon the reason her children were removed as the catalyst for getting help: I did start to get out of control and drink more than what I usually would, due to situations, basically.i didn t realise that my kids didn t like it when I drank because they never told me which didn t make me happy because yeah, I love them. (UJ, 2009) The narratives of the participants around their interactions with DoCS were occasionally rather harrowing. LS, for example, saw the removal of her children as an assailment on her personhood: I said that me and my kids needed some counselling and they took everything off me. I would never ever ask for help in my life again the DOCS worker called me a fucking Catalysts for service access 46

47 dirty junkie slut to my face and says that I am never going to get my kids back. He treats me like I am a piece of shit. I don t understand it because I am a good person. (LS, 2009) In some ways too DoCS have acted as an ally in catalysing service contact. For UJ, for example, it was the influence of DoCS that initiated her service contact. She narrates her referral pathway to the current service in the following way: By DOCS basically...i signed a piece of paper, which isn t law abiding I can have my kids back tomorrow if I wanted but, yeah, I d rather just do the right thing. So yeah and part of that was to go and do this and like I don t look at it, DOCS, in a bad way So, that aspect it was a good thing and the domestic violence that was an issue and housing. And if I meet basically those, the, this and housing and see a counsellor, which I kind of needed anyway, I get my kids back, which, yeah. It s not a law abiding piece of paper, I just volunteered to do it and you know, put my kids before my wants or, yeah, so at the end of the day, it s about them and they didn t ask to be here. (UJ, 2009) Often, the participants narratives centred upon them being competent to actually be a parent, facilitated through the rehabilitation process. SJ describes this process in the following way: I was ordered by DOCS to go to a psychologist due to having my children removed from me to see if I was fit enough to be able to have them back.may this year I gave birth to my seventh baby. DOCS removed him the minute he was born. It killed me. I needed help. (SJ, 2009) Another client, EP, who attended an outpatient drug and alcohol service, expressed a fear that any minor errors could lead to the withholding of her children: I m just scared to fail, I m scared that DOCS are going to walk through the door one day and, Hey, guess what, the toys are on the floor, and I m gone (EP, 2009). The narrative that unifies these parents stories is the devastation that the removal of their children has caused them, and presumably their children and other family members. Breakdown For some, the catalyst for seeking or getting help was articulated as having a breakdown or hitting rock-bottom. HW, a client at an outpatient drug and alcohol service, characterised his experiences in these words: The problem I had, I was physically, emotionally, mentally, spiritually bankrupt when I detoxed and I just went along with what they said If you look at the stages of how an addict goes, this time round I had to hit rock bottom to get recovery. (HW, 2009) Some of the participants identified a process of breakdown over which they felt they had not control as the catalyst for seeking help. FW, for example, reported: No, it was basically like a mental breakdown, I didn t understand what was happening to me or why, because I was always alright in the head before and then like in a period of 6 months it got really worse, probably because I was using lots more drugs. But I still didn t understand that, I thought I could take something to sleep, take something to wake up. Then one day, I think I was probably coming down and everything was just going to shit and so I went to the doctor and I said, You ve got to help me, I lie, cheat and steal for this shit [giggle], what do I do, give me a number of a rehab, I ve got to escape. (FW, 2009) Catalysts for service access 47

48 For other participants, this breakdown was linked to breakdowns in interpersonal relationships. AL, a client of an inpatient drug and alcohol service, said: It started when I was in last Christmas, my girlfriend, after three and a half years, left me. I fell into depression and started using drugs and just lost my feet for a while and started self-harming. (AL, 2009) AL was involuntarily hospitalised as result of this self-harm. CM, also a client of an inpatient drug and alcohol service, whose girlfriend had been arrested on drug-related matters, directly linked his own breakdown with the issues connected both with his own drug use and the breakdown of his intimate relationship: Yeah, I had a bit of a breakdown. I was selling a lot of drugs and the stress from that got too much, the life that went along with that got too much and my girlfriend got locked up all within - you know, the space of about 2 months all these things happened, so yeah that made me think I needed treatment again and, yeah, did what I thought would work and rang up the detox. (CM, 2009) Cognitive side effects For TM, for example, it was the negative cognitive aspects of his drug use that catalysed his helpseeking: It s just chunks of memory gone, and I couldn t really hold down all my anger and everything with weed, or with drugs anymore, so that s the reason that I decided to quit and just face everything (TM, 2009). DD s confusion centres on the thoughts he was having while he was using. He was attending an outpatient mental health service at the time of the interview, so it would be largely safe to assume that many of these thoughts were in some ways attributable to psychosis: it wouldn t go away and it would feel like I had an anxiety as well that came with it, like when you think people want to kill you, you get anxious and the anxiousness, the anxiety is what made me come here. (DD, 2009) In a similar expression to TM regarding the cognitive effects of their drug use, DD squarely places negative cognitive side-effects and anxiety as the catalyst for help seeking. Discussion For many of the participants, the catalyst for seeking or getting help was characterised by a crisis situation. For some participants, the crisis was part of their homelessness; for others, it was a result of DoCS intervention, and yet for others, it was a result of medical intervention. Extrinsic motivating factors, the criminal justice system for example, are discussed as catalysing help with these issues (Allen, 2007), but there is less literature examining personal crisis as the catalyst for getting help. Among the few, the results of van der Meer Sanchez and Nappo s (2008) study of help-seeking in Brazil are reflected in the outcomes of this part of the present study. Their study characterises various motivating events (Mackain and Lecci, 2010), such as impending job, house or partner loss, or hospitalisation, as crisis situations. It is possible that extrinsic and intrinsic motivations are highly connected. In many of the narratives of the participants, for example, the feelings associated with the loss of a partner were coupled depression, drug use and involuntary hospitalisation. At times too, the term crisis itself is avoided because of the negative associations it brings, or because the clients themselves do not view their individual circumstances in this way. The term crisis carries with it Catalysts for service access 48

49 however the possibility of positive change, the definition of crisis used here being: A vitally important or decisive stage in the progress of anything; a turning-point (OED, 2009). If HW s narrative is examined for example, multiple dimensions of crisis situations open up. When relating his first experience of detox as a time when he was physically, emotionally, mentally, spiritually bankrupt (HW, 2009), HW suggests that he had little or no resources left to manage his substance use and mental health issues. In narrating his current service contact, HW states: If you look at the stages of how an addict goes, this time round I had to hit rock bottom to get recovery (HW, 2009). There is a difference in the way HW characterises the two different help-seeking episodes. In the second instance, HW suggests that he has more resources, at least in the way the crisis, or hitting rock bottom is re-told. HW hints at the language of relapse prevention, that is, he has realised he has met a crisis point, a point of change in direction, and this is a part of recognising a substance dependence. While crisis carries with it connotations of difficulties, the term also carries the inference that direction is about to change. In the narrative of HW at least, this directional change reveals familiarity with relapse prevention education. Such a result suggests that relapse prevention education is a useful tool for people who experience substances use issues when in crisis. Further investigation could be warranted in optimising these relapse prevention education strategies. Implications for service delivery relate to prevention, and management once crisis situations have occurred. In the first instance, it may be important for workers to recognise the precursors to crisis situations experienced by their current clients. Similarly, this recognition could be important for other organisations such as helplines and community education and development organisations. Once crisis situations have developed, the results of this study suggest that it is important for the multiplicity of issues in the clients experiences be recognised. The results of this study suggest for example that while the crisis situation may be primarily centred upon drug issues, domestic violence, housing, children and employment may also be involved. Changes in all of these domains, according to the results of this study, will have an impact on when and how a person accesses a service. Catalysts for service access 49

50 Catalysts for service access 50

51 Referral pathways and service access The primary aim of this study was to investigate the experiences and referral pathways to specialist mental health and AOD treatment for CALD clients with co-existing cannabis and other drug use and mental health issues. As such it is important to first understand respondents' service use history, that is, what types of services they have had contact with, how they were referred to these services and how respondents recalled these services interacting, if at all. In asking clients to describe their service use history, the project aimed to use their responses and experiences to identify points for improvements in access to specialist services for clients experiencing co-existing mental health and drug and alcohol issues. Method In order to assist clients in recounting the services they have had contact with in receiving assistance for their mental health and/or drug use issues, the following questions were asked: What health services have you been to in the past? Can you remember when you were a client of X service? [Further probes: How old were you when you first went there? How long ago were you there?] What were you there for? What were you receiving treatment for? What were the main reasons you went to service X? What did you want to get out of your time there? Who referred you? Who brought you there? [self referral, doctor, nurse, health care workers, a drug and alcohol counsellor, telephone helpline services, staff at a detox facility, staff at a pharmacy] I have list of different types of services. I m going to go through them and ask you to tell me if you ve ever had experience with them and what it was. [Read through the card with AOD & mental health treatment options] In asking these questions it was hoped that a full service use history could be compiled for each client, detailing the types of services they have had contact with, when each contact occurred, the referral source for each contact, and whether there were any striking differences between the CALD and non- CALD participants. All clients were able to identify the types of services they have had contact with in the past. For some clients there was missing information in relation to the referral pathways for all the services they had accessed, as some found this difficult to recall. Results were analysed by first mapping each client s service use history in a spreadsheet. Each service the client identified was listed, with arrows used to indicate where one service contact had led to referral to a subsequent service. Where information was provided by the client the referral source, year of contact, and length of time with the service was recorded in the spreadsheet. The concern leading to first service contact was also recorded in the spreadsheet, that is, whether it were drug and alcohol issues, mental health issues, or both. This first spreadsheet was then summarised into a second spreadsheet containing the following fields: respondent number, cultural background, first service, first service concern, first service referral source, how long ago, current service, current service referral source, and range of services contacted. Referral pathways and service access 51

52 These results were then used to quantify service use and referral pathways across the participant group, and, alongside the narrative analysis approach employed throughout (see methods section), were used to identify patterns, commonalities and divergences among the experiences of the participant group when gaining access to specialist drug and alcohol and mental health assistance. Results Types of services accessed Of the 52 clients about half (24) had been to both drug and alcohol and mental health services, 17 to drug and alcohol services only, and 11 to mental health services only. The vast majority of clients (45) had had experience with multiple services, with seven clients only ever accessing one service, including three for the first time. Table 1 below shows the types of drug and alcohol and mental health services clients had been to, demonstrating the breadth of experience the participant group has had with service types across the two sectors. Services that offered more than one service type (e.g. counselling and pharmacotherapy, residential rehabilitation and AA groups), were categorised according to the main reason the client had gone to the service. Table 1: Types of services accessed throughout service use history Number Service types accessed of clients Mental health services s Hospital / psychiatric ward 19 Mental health counsellor or psychologist 20 Psychiatrist 14 Community based mental health residential service 13 Community mental health service outpatient service 7 Drug and alcohol services Residential rehabilitation service 30 Outpatient rehabilitation service 14 Inpatient detox 13 Drug and alcohol counsellor or psychologist 12 Pharmacotherapy (Methadone or Buprenorphine) 6 Outpatient detox 4 AA, NA or SMART recovery groups 3 Other service types The GP for referral or medication 13 Youth or welfare service 4 Women's health service 4 Refuge or housing service 3 Referral pathways and service access 52

53 In comparing the types of services accessed by CALD and non-cald clients the biggest difference occurred in relation to drug and alcohol residential rehabilitation services, where twenty-three non- CALD clients had accessed this service type before, compared with only seven of the CALD clients. The second largest difference was in relation to hospital admissions, where a higher number of CALD clients had been admitted to hospital emergency departments or psych wards compared to the non- CALD clients (13 compared to 6 clients). First service accessed In looking specifically at the type of services clients accessed for the first time, the most common first service type was an outpatient service (psychologist, psychiatrist, counsellor, or a community health service). A similar number of clients first service was a hospital admission, drug and alcohol inpatient service or a GP. In terms of the clients identifying the reason why they were at their first service, this was fairly evenly spread between either only speaking about mental health issues, or only speaking about drug and alcohol issues. Ten clients spoke of being at their first service for both mental health and drug and alcohol issues. Table 2: First service type and reason for contact (presenting issues) First service type Outpatient service Psychologist, psychiatrist, counsellor, community based health service Hospital (emergency or psych ward) Drug and alcohol inpatient service Drug Co- Mental and existing health Other* Total alcohol issues only only GP Total * Other includes involvement from DoCS, criminal justice system, homelessness. As with types of services accessed, the role of hospitals was also more significant for CALD clients over non-cald in relation to the first service accessed, where a higher number of CALD clients first went to a hospital for drug and alcohol or mental health related issues than non-cald clients (8 compared to 3 clients). Further, hospitals continued to play a greater part throughout service use history for CALD clients. Specifically, all five clients who had been referred to their current service through a hospital based psych ward identified as being CALD. Several workers spoke of the increased role hospitals played for CALD clients in relation to referral, attributing this to CALD clients accessing help due to a medical emergency or once they were acutely unwell. TM works in a hospital based early intervention service and describes her clients' referral pathways as follows: I d say probably the biggest or the most common way people are referred are because these people are referred to us when they are acutely unwell, so it is common for them to come through the hospital system. They might be brought in by families, by GP s, brought in by police. (W:TM, 2009) Referral pathways and service access 53

54 Self-managed change Within the context of accessing services, it is also worth noting that some clients also identified selfmanaged change. The context of self-managed change was largely in relation to quitting or reducing their drug use, usually cannabis. BJ was one of the clients who spoke about reducing their cannabis use without the assistance of anyone else: Well I just thought I d quit one day I just thought stuff it I m quitting so I ended up getting off it. I ve been off marijuana for nearly 3½ years and in them 3½ years I ve only tried it a couple of times so yeah, I pretty much quit, stopped for a about three years. (BJ, 2009) Some of the clients who linked the onset of psychotic and other mental health symptoms with their cannabis use spoke about how making the decision to quit was not difficult for them. DD quit cannabis on his own, and talked about his decision to quit and the process of readjusting: I was so scared, I knew that if I smoked again I d just go straight back to being paranoid and I wouldn t enjoy it. So I thought, Nah, my smoking days are over, it s a no go zone now...it wasn t hard for me to look at it and say, No, I don t want any but it was hard for me to readjust to a new lifestyle of like, no smoking, because I d been doing it for 10 years. (DD, 2009) Fragmented versus continuous service experiences Across the client group there were varying experiences in relation to whether service use history was disjointed, continuous between services, or a combination of both. Most commonly, service use history was largely fragmented and disjointed, particularly for those clients who had been accessing services over a longer period of time. Disjointed and fragmented experiences were those where each service contact stood in isolation of others, with no instances of continuous contact with a service provider, and few experiences of referral from one service to another. For some clients this fragmented service use history was characterised by difficulty in finding appropriate or suitable services for their situations. This was the case for LS, a current client at an outpatient drug and alcohol service, who had been accessing services for 20 years. LS talks about how for most of that time it was hard for her to find an appropriate service: It was very, very stressful. I went to [a welfare service] and they put me onto the counsellor at [another service] I got little bits of information from different, and I d grab pamphlets from everywhere. I had that many pamphlets hoping that I could find the right place to help me and it s, like, that was two years ago...so there was really nothing there for me that I could find. (LS, 2009) Several workers also spoke of clients fragmented service use history, largely attributing this to structural or possible systematic deficits in dealing with people who have co-existing issues. One worker spoke about the ping ponging of these people between mental health and drug and alcohol services, going on to say: the system is not underpinned by any notion of co-morbidity and I think that that s the issue, and I just think poor service delivery for people, especially say with cannabis use who, and if they re linguistically challenged as well as another, and just another layer of crap they have to put up with. (W:EM, 2009) Referral pathways and service access 54

55 Some clients whose early service use history was fragmented experienced more recent continuous referral experiences. This was true for NP who describes her initial period of help seeking as follows: I had my doctor give me an antidepressant, but I ended up taking myself to casualty, freaking out a couple of years before that I went and saw a doctor about depression And I ve seen counsellors. I ve seen psychologists I just felt like I was going around in circles and I wasn t getting anywhere. (NP, 2009) In the past year, however, NP s experience has been one of continuous referral. This began with a new doctor immediately suggesting she see a drug and alcohol counsellor, and then working with the counsellor to refer her to a hospital psych ward, followed by a hospital based detox program and then two residential rehabilitation services, the latter of which she was currently attending. Like others who share this experience, for NP this continuous service period was instigated by a worker providing a more suitable or positive service experience. Nine participants spoke of experiencing a continuous referral process throughout their whole service using history. This was either where the first service contact assisted clients in referral to subsequent specialist drug and alcohol or mental health services, or the first service contact referred onto a second service who then referred onto a third service and so on. In the past two years KW had been at four different services, with his first service having a role in each of his subsequent service contacts: I ve got a mentor...and he s helped me get to where I am now; like remarkably, it s you know, if it wasn t for him I wouldn t have had the courage to stand up and go, Right, I need help....basically, the first refuge I went to...he was a worker there and since the day I met him, we just clicked...i kept in contact with him and basically ever since like, he d help me, he d be my support person when I had to go to Court...I thank the God, I thank God, that here was a bed at [the refuge] because that s where my journey to helping myself started; and ever since then [the refuge] has helped me out a lot, like, and I mean a lot. They ve put their head on the chopping block many times for me and they re just a really good support I find, you know? (KW, 2009) Continuous referral or service contact did not necessarily mean that clients had seamless access to subsequent services. Despite his positive experience KW goes onto to talk about difficulties he experienced due to being on a waiting list for four months for the residential rehabilitation service he was currently attending. While the overarching experience of receiving help from services was fragmented and disjointed across the whole respondent group, it appears as though this was even more the case for CALD clients. The experiences of the CALD client group could be characterised as lower service engagement or lower instances of continuous referral when multiple services had been engaged. Specifically, compared to the non-cald clients, more CALD clients had only ever accessed the current service or were in their first period of seeking help from services (8 compared to 3). Further, of those who had had accessed more than one service fewer had any experience of continuous referral compared to the non-cald clients (8 compared to 16). This apparent trend is characterised by a community worker describing the experiences of two CALD clients she sees: The first one, the one from the rehab, no I don t think she was offered really any support from what I can make out The other one, I think, has. She s mentioned that she s had lots of different counsellors and stuff in the past [it] hasn t worked out all that well, she s got a borderline personality, I think and she finds it hard to engage. Cause they don t know where to go. I mean they might have been here for 20 years, they might have been Referral pathways and service access 55

56 here for three but you know they might have no conception that they would be entitled to some of the things that they might be entitled to. (W:DV, 2009) Another worker, KR, also spoke about the fragmented contact with health care providers experienced by the CALD clients he sees. As with DV, KR also went on to talk about this largely being due to the clients not knowing what services were available: Because we re working with what s deemed as quite marginalised young people and their families, it varies. But what we find is they generally are not in consistent contact with health care providers, whether that be primary care providers or secondary care provides the Allied Health Services A lot of the time that s because a lot of CALD clients are sometimes are not aware of those services existing in the first place, especially the secondary ones So for us it s about being able to provide a response for the client to engage with those providers. (W:KR, 2009) KR goes on to identify that as well as a lack of knowledge of those services existing, other reasons for limited service engagement includes cultural taboos, shame and stigma: for example, some of the sexual health services that might be on offer. In some cultures that might be deemed as inappropriate and not suitable for that particular age group especially young people so they won t access that and/or because of the shame factor of being able to probably see a service and potentially be caught out for seeing that service as well. So there are some stigmas attached to accessing health services and what that might and what that might mean for the future. (W:KR, 2009) Repeat visits to the same service Many clients spoke of repeat visits to the same service. The most common of these were repeat admissions to hospital based psychiatric wards. This ranged from two admissions, to one client who estimated that she had been admitted about 15 times in the last 5 years. For three clients their current service was the only service they had ever accessed, with all three identifying as being from a CALD background. A few clients who had accessed their current service in the past spoke of their current contact with the service involving a greater sense of individual agency or self motivation. For example, BR estimated that she had been admitted to the hospital based psych ward she was currently attending about six times in the last 16 years, but her current service contact was the first time she had admitted herself. Similarly, AJ spoke of his previous contact with the current inpatient mental health service he was attending. For him too his current service contact was self-referral: I was here for a year and then I got kicked out [previously]. And then when I come back from Melbourne, I rung here and they said, Yeah, there s a bed. And I said, Yeah, I want to take it. And then I was put in the hospital again, and they gave me some meds and then I was put back in here. So I reckon it s the best thing that s happened. (AJ, 2009) FW also spoke about her increased motivation in her current service contact: this time because I m here a year later, I ve got a whole lot more insight now it s so much more different this time (FW, 2009). Referral pathways and service access 56

57 Most clients identified that the reason they went back to the same service was because they liked the service. For some other clients it was because they did not know where else to go, as was the case for NR who says: I didn t know where else to go and I ended up going back into hospital because I was just frightened of what was going on because I was pretty anxious I put myself back in there because I wasn t dealing with things the way I should be. (NR, 2009) Referral pathways Clients were asked about their referral pathways into the services they had attended. This section pays particular attention to referral pathways into the first services clients accessed and the service they were currently attending (i.e. the service through which clients were recruited for this study). The three clients who were currently engaged in their first service contact at the time of interviewing are excluded when looking at current referral sources. The tables below summarise these results. Table 3: First service and referral source First service Outpatient service Psychologist, psychiatrist, counsellor, community based clinic Hospital (emergency or psych ward) Criminal justice system Family Self DoCS Other 1 Total Drug and alcohol inpatient GP or medical centre Total Other includes school, ambulance, and housing refuge. 2. Total does not add up to 52 as referral source was not ascertained for all participants. Table 4: Current service and referral source Criminal In- Out- Current service justice Family Self patient patient Total 2 system service service Drug and alcohol inpatient Mental health inpatient Mental health outpatient Drug and alcohol outpatient Total This includes one client who was referred by DoCS, the rest being drug and alcohol or mental health specific services. 2. Total does not add up to 52 as referral source was not ascertained for all participants, and current service table excludes 3 other clients who were engaged in their first service contact. In the following sections client experiences with the referral pathways identified will be presented. These being self, family, the criminal justice system, and other services. The GP is then discussed separately as the role of the GP in clients pathways to service access is not reflected when purely looking at sources of referral, yet was significant and unique compared to other service types. Referral pathways and service access 57

58 Self referral For referrals to both initial and current services self-referral was the most common referral source. The contexts of self referral includes participants making contact and taking themselves to a service, with some finding out about appropriate services themselves and others asking someone else where they could go to for help. Those who were advised to see a service and provided a number by someone else were not counted as self referral, even though they may have called and presented on their own. The role of individual agency in the latter scenario will be discussed in the sections to follow. First service The most common first service type for those who self-referred was the GP. Most of these six participants had taken themselves to the GP with the aim to receive assistance, or a referral, for their mental health or drug and alcohol issues. For LH this occurred after living with psychotic symptoms for a period of time: Um well, I started hearing voices when I was about 13 and they were a bit frightening and at first, I just thought it might just be something that has come and it will go away but then they started getting worse and worse so I decided to go and see the doctor about it. (LH, 2009) Several other clients spoke of being told of a drug and alcohol or mental health service by DoCS workers, or a welfare service. LW describes her process of self-referral to her first service by saying I put myself there. But DOCS said that there was places like this for me to go...i rang up. I done it all myself (LW, 2009). For those who had self-referred directly to a drug and alcohol or mental health specific service about half spoke of the involvement of either family or peers in helping them find a service to call. MA, for example, had her first contact with a drug and alcohol service in 1989, when she booked herself into a residential detoxification service. In response to how she got to the service MA says that she found out from other users, whereabouts to go. I was homeless at the time and when you re homeless you get to know everyone around (MA, 2009). The remainder of participants did not speak of anyone else being involved in the process of their first engaging with a specialist drug and alcohol or mental health service for the first time, mostly stating that they just knew of the service, or had put themselves there with no further detail. There were no apparent points of difference between the CALD and non-cald respondents in relation to self referral to their first service. Current service Compared to first service referral, a higher number of clients self-referred into their current service contact without the involvement of anyone else in the process. This was true for more than half of those eighteen clients whose pathway into their current service contact was self-referral. This increase in self agency, however, appeared to be less true for the CALD clients compared to non-cald, where, among the 10 clients whose referral did not involve anyone else, only three were CALD. In looking at the services clients had referred themselves to, five had booked themselves into a service they had had contact with in the past. The remaining thirteen had booked and taken themselves to a new service, EP for example had searched on the internet for it and I wanted to Referral pathways and service access 58

59 come here first so then I just put my name on the list (EP, 2009). For UM, his repeat contact with a service came after 20 years: I was clean for 20 years which is a really long time to put myself back in here, it was a really drastic move and I know that I could have done it on the outside, I knew there was a lot of support systems. But for me I really felt like I needed to come back to basics, and they allowed me to just work on a 2 week program instead of completing. So they were really flexible and I just had to pick up the phone. So knowing that the service is here, knowing that it works, but also knowing that if it wasn t working for me I could leave at any time, all that was really, really helpful. (UM, 2009) For those whose self-referral into their current service involved someone else there also appeared to be a greater sense of individual agency compared to first service self-referrals, largely stemming from a greater understanding of where or when to seek help. All of these involved clients telling someone else about the issues they were having and their desire to seek help to address these. The most common place clients went to for information about where they could get help were drug and alcohol or mental health professionals, either those they had current contact with, or as was the case for two clients, by calling the ADIS number. This was true for VY who had trouble finding a rehabilitation service after she completed detox: Then I was waiting and waiting, there was one that I could maybe have got into in a few weeks, but it was way down at [an inner city location] I would never have seen my son so I was looking for ones closer down here I was on the waiting list for about four months. I was clean. I was on about three of them, some of them you had to ring every day, others you had to ring once a week, I was doing that religiously. In the end, I gave up. I thought it was so hard I really gave up then and it was just only when I started having grand mal seizures that I thought, This is ridiculous, I ve really got to get into rehab again So I again off my own back I phoned ADIS, got a list of rehab centres and started phoning them. Got on waiting lists again. This time I tried about seven and even looking as further afield Then for some reason I had to phone ADIS back and I said, Look I know there are a couple of hospitals that have a detox centre that I apparently could get into fairly quickly, can I have their number? I can t find the detox centre. They said, Oh yes, and have you tried other places? I said, Look I m on the waiting lists for rehab centres but honestly there are none in [my area]. and he mentioned [the current service]. (VY, 2009) Compared to the level of involvement of others in the self-referrals for first service contacts, the role of family members or peers were much reduced in the current service referrals, with only two clients getting the number for their current service from a friend or family contact. There were no real differences between the CALD and non-cald respondents in relation to the involvement of others in their self-referral to the current service, this was the case for five CALD clients and three non-cald. Family referral For those clients whose family had played a role in their referral process, family involvement ranged from family instigating and facilitating the service contact, to family helping them find a service to contact themselves, to those clients who contacted services after realising the impact their drug use or mental health issues was having on their families. Referral pathways and service access 59

60 First service Ten clients indicated that they were referred to their first service by a family member. Family as a first referral source was more significant among the CALD client group than non-cald (7 clients compared to 3). In relation to referral to the first service contact for drug and alcohol or mental health issues, those respondents who spoke about their family involvement spoke of active and direct involvement on behalf of their family in getting them into a service. This is particularly true for those, like TP, who have had contact with services from a young age: I got, not kicked out of school but pretty much asked to leave, as they do, for, I don t know whatever I did So after that Mum thought I was going downhill, I guess I was I don t know. She made me go and see this guy. She s always been making me go and see counsellors and all that my whole life, so, yeah. I normally just go to them once and go, Nuh, didn t like it, hated it. (TP, 2009) For those whose referral source into hospital was family this also involved direct intervention by family members taking the individual to the hospital, normally parents, but not always as was the case for NF: my brother-in-law took me straight to the hospital and then she said I was alright, the lady, the nurse that was in there, and my brother-in-law it didn t sit right with him so he took me to his doctor and doctor writ (sic) up um up a a a referral saying immediately put him in and they put me in straight away and I was there for a month. (NF, 2009) While family involvement was usually spoken about in relation to more direct actions taken as described above, this was not always the case. Several clients whose first service access was seen as a self-referral, also described the less direct role their family played in the process. This is evident in CM s narrative as he talks about first seeking help for his drug use when he was 17: I realised I had a problem with drugs and smoking because I had been smoking since I was 13 and, yeah, just realising that I didn t feel right unless I smoked every day. It just, you know, rang some alarm bells. I lost some jobs because I was turning up stoned every day, yeah, and also my mum tried to help me get some treatment and, yeah, just found the don t know where I got the number from, but yeah, found the community health centre and they really helped. (CM, 2009) When looking at the influence of family in the referral process, perhaps more complex to identify is the indirect role familial relationships, as opposed to the actions of family members, have played in relation to clients decision to refer themselves into services. A few clients spoke about this in relation to their process of self-referral, either in relation to their relationships with their children or their parents (see the previous chapter for further discussion of DoCS involvement as a catalyst for seeking help). EW, for example, describes how his experience of depression and decision to see a psychologist was motivated by how his mother was being affected by his involvement with the criminal justice system: I was a bit depressed about the Court matters, because me mum and that found out about it and yeah, she was really depressed about it. I could see what it was doing to her, so it made me feel really depressed inside so, she wanted me to talk to a psychologist, because she thought that I was down and out. But my down and out was more sort of coming from her, her being so down and depressed and about my situation. (EW, 2009) Referral pathways and service access 60

61 Several workers recognised that family intervention may be more significant for clients from CALD backgrounds and spoke of the implications this may have when working with clients and their families. Workers CA and BP spoke about how family inclusive practice was essential for some of the cultures they worked with: Well in some cultures, it s the only thing because a lot of our different cultures, all that decision-making in terms of...treatment...it s actually left to the family to decide. It s not so much the patient or the client, it s very much a family thing and a lot of times there s so much, there s all this red tape about disclosure and privacy. (W:CA & W:BP, 2009) As well as privacy issues YL spoke about some of the additional challenges experienced when working with families of clients: One: it can be difficult to get information from [a] client, if there s a family member present or accurate information. Two: sometimes it s difficult getting across our ability to respond or how we respond to a problem when that s, when we re not able to immediately meet the need what they want sometimes isn t what we re able to give. (W:YL, 2009) Workers also described particular strategies in their work place to better facilitate working with families and carers. One worker described a consultant from a particular CALD community that visited their workplace to talk about effective ways they could engage with family members who "did not want to bring their child to the public health system" (W:EF, 2009). Two other workers spoke of specific family worker positions, one was a new position yet to begin, and the other was one which unfortunately no longer existed, as TM describes: that family worker would do family assessments for every referral that would happen, but that position was kind of dropped and changed to another position...that s how I kind of work anyway, but essentially we try and engage the families. But it s not as, I guess, formal as it used to be, where we all had the role of asking about family dynamics and, and working with the families. (W:TM, 2009) Current service Comparatively with first service access, family had a lesser impact across the participant group in relation to referral to the current service, where only two participants were referred to the current service by their family, and one self-referral was influenced by family. Criminal justice system referral For clients who had been referred into services through their contact with the justice system referral sources either included a court order or Magistrates Early Referral Into Treatment (MERIT) involvement, or referrals from probation and parole. As EF describes: Umm, basically it was Court Order to start with, you know like I came out of custody and the Judge sort of give me the chance at the rehabs...yeah, it s just basically what the Courts want me to, basically complete a program, you know which I ve sort of got a bit of here and I will, so yeah. (EF, 2009) Those whose current referral source was criminal justice-related were all currently in a drug and alcohol service. Despite recent or current involvement with the criminal justice system, clients still Referral pathways and service access 61

62 spoke of individual agency and choice in being at their current drug and alcohol service. QH describes his experience as follows: They [probation and parole] had a number of services, a lot of them in the city and this one seemed right for me. Being a little bit closer to home too, it was only like get on a bus and a train So yeah, this umm, they didn t push me into it, there was a choice there. So by the time I went back to court I was already, I d already booked myself into this programme. (QH,2009) For another client, BM, his previous service use history was taken into account in his current referral by the court: DoCS took my kids at Christmas and I was arrested for a couple of charges as well and then it s been a court matter and they knew I d come [to the current service] from past experience and didn t want to burden the welfare and rehab and this one s only, for me it s 6 weeks. So yeah, I ve got 6 days to go and a lot of change has happened and I m pretty happy, you know? (BM, 2009) Those clients who indicated that attendance was court ordered, or part of bail conditions or a suspended sentence, also spoke of choice in relation to which drug and alcohol rehabilitation service they attended. This is exemplified by TM s description of how he came to be at his current service. As part of TM s bail conditions he was required to remain at the service for three months, yet when asked who referred him to this service he replied: Just a few of my friends who had been here said that it would be really good, it s a good program so I was pretty interested and I came in (TM, 2009). There were no emergent points of difference between the CALD and non-cald respondents in relation to the criminal justice system as a referral source to services. A couple of workers however stated that more of their CALD clients were referred to them through the criminal justice system compared to their other clients. This was true for UW who describes the referral sources for his clients as follows: I guess the ones who haven t been sent to us through Juvenile Justice or Youth Drug Court then they will usually be self-referrals so it might be their family that will realise that they have a drug and alcohol problem. But I guess, the ones from the diverse backgrounds and different nationalities, more than often are sent through Juvenile Justice. (W:UW, 2009) Service referral Other services were the referral source for initial drug and alcohol or mental health service access for seven participants. Four of these were referred by DoCS, two by refuges and one brought to their first service by ambulance. UJ had her first service contact in 2007 when she went to see a psychologist for her drug and alcohol issues. She says of her referral process: I was ordered by DOCS to go to a psychologist due to having my children removed from me to see if I was fit enough to be able to have them back (UJ, 2009). Referral from other services played a more significant role in relation to referrals to the current service, with fourteen participants being referred to their current service by another drug and alcohol or mental health service. For six of these clients it was a service provider they had had ongoing contact with for a period of time who referred them to their current service. This was true for NB who was referred into Referral pathways and service access 62

63 his current residential rehabilitation service by his outpatient drug and alcohol counsellor. He described the long-term positive relationship he had with his counsellor, saying: I ve been seeing a counsellor for the last six years, the same guy, in where I live. And yeah, I see him once a week. Even when I was clean for the four years, I still sort of kept in touch here and there my counsellor told me to come here, because he finds that what they do here, he said it would suit me more, and he thinks it s a better program for me, and he s very similar to me. He went through all addiction and that and came out the other side. (NB, 2009) Other clients were referred by services they had had more recent contact with. This was the case for QM who was currently attending an inpatient residential rehabilitation service after being referred there from an outpatient drug and alcohol service he found by searching online. Unlike NB who was referred by a worker he had had long-term contact with, QMs positive referral experience was from a brief contact and intervention. He describes the process as follows: But as soon as I called [the outpatient service] I got a call back about 40 minutes later from a caseworker, had a really good chat with them on the phone and I said to them, Look I really don t think that just doing a counselling service once a week is going to work. I need to get out of my environment for a while. So he started ringing around rehab centres for me looking to see who had places and it happened all very quickly from there. It was about 5 days after that and I was here. (QM, 2009) Unlike QM, most clients who spoke about the process of referral from one service to another did not experience the same level of involvement from the referring service. The situation was usually one where the current service or worker would suggest that they needed to see another service, and give the number to make contact with that service, and clients would then arrange the contact and the process for themselves. In these circumstances clients usually identified their own individual agency in the referral process. This was evident in BJ s description of how he found out about the current inpatient mental health service he was attending: My counsellor, caseworker, I don t know what they re called, but she suggested this to me so, yeah, I decided to come over here (BJ, 2009). In comparing the CALD and non-cald client groups, it would appear that outpatient services were more likely to be a referral source for clients of Anglo-Australian background and hospital a more likely referral source for CALD clients. Referral from an outpatient service was more common among the Anglo-Australian clients compared to the CALD clients (6 compared to 2). Whereas, as previously mentioned, hospitals played a greater role as the referring source to the current service for CALD clients, where all of the five clients in this group identified as being from a CALD background. The role of the General Practitioner (GP) Twenty-nine of the participants spoke of having contact with a general practitioner specifically in relation to accessing help for their drug and alcohol or mental health issues. Participants discussions about their contact with GPs reflect a diversity of experiences and functions, more so than any other service provider spoken about. GPs appeared equally as important in the service use histories for clients of both CALD and Anglo-Australian backgrounds, with no emergent differences between the role of GPs across the client group. Referral pathways and service access 63

64 Given the nature of services provided by a GP, the GP was included as a service when clients spoke of accessing a GP in relation to receiving help for drug and alcohol or mental health issues. As such the GP was the first service accessed by ten clients seeking help for mostly mental health issues, with two looking for help with drug and alcohol issues and two for co-existing issues. After contact with the GP six clients received a referral to a psychiatrist, psychologist or counsellor, with one being referred to a hospital emergency department. Most of these clients spoke of purposefully taking themselves to a GP with view to receive a referral for assistance. In these circumstances the clients did not know what actual services were available to them, even though they may have been aware of general service types that would be helpful. DD, for example, spoke about how he first went to the GP with view to get a referral for his mental health issues, his GP then told him about how he could access a psychologist through Medicare and made the referral: I did see a Psychologist a couple of years ago a private Psychologist that I hooked up through my GP. They got it through Medicare. It was twelve free, twelve sessions through Medicare that was I think about 2 years ago. (DD, 2009) Similarly, EW went to see his GP, who also then made a referral through Medicare: I wanted to try and stop smoking pot and he [the GP] gave me a referral to a psychologist and I tried do go down that path (EW, 2009). The role of GP and other health professionals in informing clients of the availability of the GP Mental Health Care Plans was highlighted by one worker: Referral pathways and service access 64

65 ...what normally happens if you re talking about...the Mental Health Plans that they have in place now.we actually share that knowledge with the participants about that existing in the first place So a lot of the time, a lot of young people are not aware of that sort of service that exists now through Medicare. (W:KR, 2009) A couple of clients also spoke about their GP being more involved in their referral process by proactively suggesting they seek further assistance. For NP this occurred after previous negative experiences with a different GP and other services. She says of her current doctor: I went and started seeing my doctor, he s the only doctor, or person I ve found who has actually helped me. And he suggested it straight away that I go and see a drug and alcohol counsellor. I think he lined it up for me even. (NP, 2009) For some who attempted to access assistance through their GP, their initial experiences were less positive than those described above. QM went to his GP for neck pain, and while there decided to tell the GP about his feelings of depression, asking if he could recommend some sort of counselling service. He recounts the dialogue: I said, Well look I don t know, it s a bit chicken and the egg sort of thing, I don t know which came first, the depression or the drug usage it s all very tightly tied together, and as soon as I said drug usage the doctor s eyes just went blank and they really didn t seem to want to hear anything about it. They just said, Well you ll have to make an appointment with a psychologist and I said, Well can you recommend any services? No. So that was pretty useless Yeah well I knew the GPs could do referrals but this particular doctor, as soon as I said drugs just didn t seem to want to have a bar of it. (QM, 2009) Two years later QM tried to seek assistance again, finding a service through an internet search who then referred him to the residential service he was currently attending. Other clients also spoke of GPs suggesting they seek assistance without providing particular numbers or services to call. As CM recalls: I ve talked to a couple of different doctors and they have suggested I get help for mental health, but have never really suggested anything in particular or have anyone I could call (CM, 2009). Similar to QM, LH s negative experience when he asked for assistance from his doctor at age 13, resulted in him not being in contact with services again until he was admitted into hospital aged 19: The first service would be my local doctor, when I was first suffering from symptoms of psychosis and depression he didn t really understand what I was talking about so... kind of led me astray he sort of referred me to services that weren t suitable for my illness. Like they weren t about psychosis or anything, like so he wasn t understanding what my diagnosis was. (LH, 2009) For LH this initial period of was followed by a second period of continuous service contact six years later, which began after he was admitted into hospital for self-harming. He goes on to conclude that: I just think I could have been treated by my local doctor a lot earlier before it got too intense (LH, 2009). Unlike the previous clients, in LS s experience their GP contact not leading to referral or appropriate service contact was due to her not being ready to seek help when the GP offered referral: I ve been living in [suburb] for 20 years so the GP has known my history and that I was on speed, because I ve always told the truth when I ve gone there. And they wanted to Referral pathways and service access 65

66 put me on, like, Valium, and I didn t want to go on any pills because, yeah, I didn t want to get deeper into anything, but there was no, really, services or anything available for me from there, either They have offered [referral into counselling] to me, but at the time when they offered I wasn t ready. (LS, 2009) For LS it was not until she spoke to a worker at a welfare service that she accepted their advice about counselling and began her search for an appropriate service. She explains it as follows: I felt like what I told the doctor was over and over and over, I wanted to tell someone new and start again (LS, 2009). As identified in LS s narrative, the role of the GP as experienced by participants also went beyond that of referral or access point to other mental health or drug and alcohol services. For some clients, like LS the GP was someone they could discuss their situation with. This was also true for NF who says that he went to see the local GP and he asked me how I was feeling and I told him (NF, 2009). While LS and NF could discuss these issues with their GPs, worker DV spoke about a reluctance by some to disclose drug and alcohol use to the family doctor due to confidentiality concerns and fear that the GP would tell their parents or other family members. The more common non-referral role that GPs played was as prescribers, where eleven clients specifically identified going to the GP for their medication. For participants in this study this was in relation to medication for mental health issues; no clients spoke about going to the GP for drug and alcohol pharmacotherapy treatments. For those who saw the GP for medication there was often involvement with another service provider, such as their current service, or a counsellor or psychologist. A few clients spoke of experiences where a GP prescribed medication for mental health issues without involvement of other services, these included both positive and negative experiences. DM reflects on his experience of this: Well my GP just put me on pills but, coming here, I ve learnt that I should actually be seeing a psychologist or something as well to work through the issues, why I suffer depression but he [the GP] didn t really do anything towards sending me that way. (DM, 2009) Worker TM also spoke of the difficulties involved with some GPs misdiagnosing clients and prescribing accordingly, particularly as often times when people are becoming psychotic or are psychotic they will present as depressed...because of their beliefs that they are being followed or poisoned (W:TM, 2009). BT who works at the same service as TM also spoke about difficulties that arise when GPs take on the responsibility of treating a client when early referral may be the better option: So sometimes we don t get referrals early enough specific to our service, so GP s will take on the responsibility of treating them and treating them erratically and without any intensive assertive outreach but sometimes we get them [referrals] very quickly...it s impossible for GP s to do lots of intensive work. So they end up with us when things go out of hand. (BT, 2009) BT goes onto talk about how they found this happens more often with GPs and clients of particular CALD backgrounds, with the motivation by the GPs generally being to take care of the family and protect the client by treating the person themselves. Referral pathways and service access 66

67 Discussion For many clients there were multiple influences at play in their process of making contact with services. Clients service use history and attempts to access specialist drug and alcohol or mental health services highlighted the difficulties experienced by many in engaging with specialist services. In an effort to access help for mental health and drug and alcohol issues, nearly all the clients had been to multiple services, with many having a long history of going to different services to try to get help. Access to different services was usually disjointed, particularly for the CALD clients. Compared to clients of solely Anglo-Australian backgrounds, fewer of the CALD clients had been linked from one service to another and more had only ever been to one service. This suggests a more limited engagement with the health care sector among the CALD clients. This more limited engagement is also further highlighted by hospitals being more accessed by the CALD clients and residential drug and alcohol rehabilitation being less accessed compared to clients of Anglo-Australian background. The reason for this more limited engagement could be due to the significant role that agency and motivation played in clients pathways to accessing specialist mental health and drug and alcohol issues. Successful engagement with appropriate services seemed to be largely contingent on clients capacity to navigate the sector themselves, recognising when interventions were not appropriate for their needs and finding more effective services. Although still strongly present, these themes of agency appeared less apparent among the CALD clients, with workers identifying that this was largely due to additional barriers such as language and more limited understandings of the healthcare system in Australia. It is here that referrals by health professionals have the potential to be particularly influential in facilitating clients engagement with appropriate care. Unfortunately among the CALD clients there were fewer instances of service-to-service referrals. For these CALD clients this gap seemed largely to be filled by family involvement helping clients to find appropriate services, admittance into hospital, or accessing one service only. For those who were suggested or told of a service by another service provider, tied in with this is how far a worker becomes involved in the referral process and the helpfulness of the referring worker. Referrals can be categorised as either a cold or warm referral, which, as are defined by Clarke and Forell as follows: 'cold referral' [involves] providing information about another agency or service so that the client can contact them 'warm referral' involves contacting another service on the client's behalf and may also involve writing a report or case history on the client for the legal service and/or attending the service with the client. (Clarke & Forell, 2007: online) More often than not among participants the experience of referral from workers was a "cold" referral, where a worker would pass a number onto a client and it would be up to the client to call and make an appointment. In the case of referral from the criminal justice system, this was also true for some clients who chose to attend their current service and arranged it themselves. In these situations clients acknowledged their role in the referral process, with some seeing this as self-referral as they made the appointment and took themselves to the service, whereas the service provider would likely count themselves as the referrer. Warm referral was more often experienced in relation to family, such as those experiences where a family member had taken the client to a service, such as a hospital for admittance to a psych ward, or a GP. This was more common among the CALD clients than those from Anglo-Australian backgrounds. Referral pathways and service access 67

68 Clarke and Forell (2007) identify that while many people may only need to be told of a service to contact, the research suggests that people with complex needs may require more intensive support (2007: online). The predominance of cold referrals by workers amongst a population group that is experiencing co-existing drug and alcohol and mental health issues is, therefore, particularly concerning, especially when low English proficiency or limited understanding of the Australian health and welfare systems is also added to the complexity. On seeking advice from health and welfare professionals, some clients spoke of negative experiences, inappropriate referrals and accessing a multitude of services in an effort to find suitable assistance. Results from research conducted in the UK on public use of legal advice and information services demonstrates the occurrence of referral fatigue (Genn et al., 2004). This was where the likelihood of people actually obtaining advice after having been referred on by an adviser declines with each adviser who makes a referral, that is, people are less likely to follow up a referral as the number of an adviser in the sequence increases. In their analysis Genn et al. suggest a level of exhaustion among participants resulting from being pushed from adviser to adviser (Genn et al., 2004:31). Given the immense long term resilience and persistence demonstrated by some of the participants of the present study in order to successfully access appropriate services, despite multiple inappropriate referral experiences, it follows that there are those who would not persist. We are thus led to the same conclusion as Genn et al in stating: It is therefore unsurprising that some will feel unable to maintain the necessary level of persistence and to invest the necessary amount of time to follow up repeated referrals on in order to obtain help with their problems. (Genn et al., 2004:31-32) This would be particularly true for those experiencing co-existing drug and alcohol and mental health issues, where, depending on their level of functioning and wellness, it can take a great deal of effort for someone with a mental health problem to come into a bureau or other voluntary organisation. If they are then referred to other agencies...they may well be lost to help (Cullen, 2004:85). This can only be further exacerbated for those who do not speak English well or at all, or understand the health system in Australia. These results demonstrate the need for continued improvement in referral processes to services that are appropriate and sensitive to the needs of those experiencing mental health and drug and alcohol issues, particularly for those from CALD backgrounds who may experience less service-to-service referrals than their Anglo-Australian counterparts, yet appear to have more limited engagement with specialist services. The GP has a more significant role in pathways to services than is indicated by purely looking at referral source, with the role of the GP appearing equally as important for both clients of CALD and Anglo-Australian backgrounds. For those whose first service was a GP, the GP was often the facilitator of a client seeing a psychologist or psychiatrist through referral. For many clients the GP was involved in their service use history in more ways than just as a referral source, particularly in relation to prescribing medication related to mental health issues. The diverse experiences among the client group in relation to GPs demonstrates the important role a GP can play in supporting and facilitating service access, and the impact an individual GPs knowledge and attitudes has on whether or not clients access effective help. In light of referral fatigue an effective response by a GP is particularly crucial in a client s successful access to appropriate services. These results demonstrate that GPs should continue to be supported and equipped to deal with mental health and drug and alcohol issues amongst their client group, as their response, particularly for those clients first attempting to seek help, will either help or hinder those clients accessing specialist assistance for mental health and/or drug and alcohol issues. Referral pathways and service access 68

69 The main differences between referral sources for first service contact compared to current service contact was in relation to the role of family and the role of other services. Specifically, family referrals played a more significant role in terms of first service contact, whereas in current service contact family referrals are minimal, with referrals from other services increasing in significance. While selfmanaged change was not extensively explored within the interview context, given that the focus of the project was pathways into services, the importance of self-managed change, particularly in relation to the management of substance use issues became evident. This is particularly pertinent to the experiences of most clients particularly considering the often fragmented experience of help seeking, and times, such as waiting times between detox and entering a residential rehabilitation, that rely on clients to maintain a period of abstinence. What is highlighted among participant experiences is the complexity of the referral process, and the difficulty of categorising the referral source, which may often discount or downplay the individual agency of the client, overemphasising the role of the referring service. The narratives of clients make it apparent that accessing appropriate care is largely contingent on knowing how to navigate the sector and services, recognising when inappropriate referrals are made, having the agency and motivation to make bookings, be on waiting lists and present to services as required. Overall, clients interviewed demonstrated these capacities in their service use history, some successfully booking and timing detox before going into residential rehabilitation, others researching service options either online, through ADIS, by collecting pamphlets or asking around, and still others approaching different services when the waiting list on their first choice was unsatisfactory. While agency was significant across the whole client group, such stories of great motivation and endurance to find the right help were less apparent among the CALD clients. These results again highlight the significant barriers that exist in successfully navigating the system in order to access an appropriate drug and alcohol or mental health service. The addition of language barriers and more limited understandings of the Australian healthcare system appeared to only further exacerbate the already disjointed service delivery experienced by many of the respondents interviewed. Referral pathways and service access 69

70 Effective approaches Part of the aims of this study was to enumerate the approaches that clients reported as helpful. By doing this, the aim was to point to clients perspectives of what worked and what didn t in their experiences of receiving specialist assistance for co-existing drug and alcohol and mental health issues. It is timely after nearly ten years that the suggestions made by Reid, Crofts and Beyer (2001) [see Literature Review] be re-examined in this context in order to gain a more contemporary insight into mental health and drug and alcohol service provision in an increasingly diverse society. In doing this, the aim is to provide services with information on how they can build on the effective service delivery already accomplished, and possible areas where services may be improved. In this section too, three other key elements of the clients experiences are discussed: empathy, non-judgmental approaches by workers, and the significance of group cohesion. Beutler et al. (1994) for example, discuss the significance of empathy in a therapeutic relationship. More recently, Judith Jordan, has summarised the various ways in which empathy has been seen in the context of therapeutic relationships, often relegated to a supporting role (2000: 1008) and facilitating a therapeutic context in which an individual can learn coping skills (2000: 1008). Jordan (2000) discusses the underlying principles of the Stone Centre s relational/cultural model of empathy in therapeutic contexts, namely that therapy relationships are characterized by a special kind of mutuality, mutual empathy is the vehicle for change in therapy and real engagement, and therapeutic authenticity is necessary for the development of mutual empathy (2000: 1007). It is from this standpoint that the experiences of the clients in this study are discussed. It is here held that the empathetic approach of drug and alcohol and mental health workers, and the mutual empathy this approach encourages aids in re-connecting the clients with society more generally. As Jordan suggests, Cultural issues as well as sociopolitical forces are central to people s functioning (2000: 1007). In light of the relational/cultural model, it is here suggested that: Method Isolation is one of the (if not the) primary sources of suffering in people s lives and also points to movement out of isolation as one of the main achievements of therapeutic intervention. Thus, empathy becomes not just a way of knowing another s subjective experience but a way of actually experiencing connectedness. In empathic joining, one comes out of isolation and begins to believe that one is worthy of empathy, connection and love. (Jordan, 2000: 1008) In order to elicit from the clients the approaches they had found helpful, the following questions were asked: Was there anything that services you have been to did that you found particularly helpful? [If yes, what were they? i.e.: access to an interpreter, understanding of cultural background, involved family members, same culture clients in the services, varied culture clients in the services.] Of the services you have been to, which ones were good at working with people from different cultural backgrounds? [what is it about the service that makes them good at working with people from different cultural background/s?] Of the services you have been to, which ones were good at working with people with both drug dependency issues and mental illness? [what is it about the service that makes them good at working with people?] Effective approaches 70

71 Additional material in this chapter was also drawn from the clients responses to the following: How do you think services can better help people from non-english speaking backgrounds? How do you think services can better help people who experience both drug dependency issues and a mental illness? Similarly, the following questions were asked of the workers of drug and alcohol and mental health services: In your experiences what have been the difficulties in working with clients who have a comorbid AOD and mental health condition, particularly in relation to cannabis use? In your experience, what have been the strengths of working with a client with a comorbid condition? What has made it easier for you? What has made it easier for the client in treatment? What can services do to improve treatment outcomes for people from a culturally diverse background who have comorbid AOD and mental health issues? Do you know of any initiatives that have worked well? What do you think your service does well in their work with clients from culturally diverse backgrounds? How do you think your service can improve in treating culturally diverse clients? How do you think services can better help people from culturally diverse backgrounds? How do you think services can better help people who experience both drug dependency issues and a mental illness? In asking these questions, the aim was to re-examine that which both clients and workers thought affected in both a negative and positive way the experience of therapy. Results - Therapeutic methods The results section comprises two distinct yet highly connected aspects of the expressed experiences of clients of drug and alcohol and mental health services. Part 1 centres upon the ways in which the clients and workers talk about the therapeutic methods used. Part 2 centres upon the narrated experiences of the effects of the interpersonal aspects of attending a drug and alcohol or mental health service. Among these interpersonal aspects, empathy and non-judgmentalism from practitioners, as well as group cohesion, feature prominently. Medication as largely helpful Medication is commonly used in approaches to mental health and substance dependence. Experiences with various medications for mental health issues particularly featured largely in the responses of the clients. ND describes for example, how a drug health service prescribed him the medication that in his experience helped him the most with his mental health issues: They changed my medication, they put me on a better antidepressant so that helped out a lot cause the other one that I was on from my doctor [GP] was making me sick every Effective approaches 71

72 day. But I told him that and he didn t change it. But when I went there I told them that, and they said, Yeah, we ll change it. (ND, 2009) TM, for example, a client of the same inpatient drug and alcohol service, commended the use of medication as a way that he could productively get on with the activities of the day: I m on Zyprexa now, which is pretty good. It acts as a sedative, so I take it at night so when I wake up I m really chilled and so I don t need to take it in the morning (TM, 2009). At the same time however, TM expressed an awareness of the potential outcomes of dependence on medically-prescribed medications: Even prescription drugs. People shouldn t really get on it unless they know what the side effects are. Cause when Doctors prescribe they go, yeah this will sort out this and this and this, everyone just believes what the Doctor says. And they go, Yeah okay, I ll take it, and they start going a bit crazy. The Doctor s like, Okay, yeah; I ll put you on this one as well. So by the end of it they re taking five different prescription drugs, which is no better than smoking weed or doing other drugs. It s fucked them up. (TM, 2009) TM contextualised this within his personal experiences and the experiences of his friends and associates after they had sought medical intervention for their drug and alcohol and mental health issues. Some clients described too how finding the right medication had been a hit and miss experience. AR for example describes his time in an acute mental health facility as a time of finding the appropriate medication for him: Different medications, just basically found a medication that worked for me, monitored me for a few months and released back into the care of hospital (AR, 2009). Others contextualised their experiences of different medications within a framework of what did, or did not, work for them. AL, for example, says, Some of the medication that I was given really didn t do much for me. Until I was prescribed proper medication, that s where I was starting to feel a bit better about myself (AL, 2009). Healthy alternatives to medication Other participants expressed apprehension around the prescription of medications out of personal choice to manage their mental health issues in alternate ways. AJ for example characterises his experiences of the approach of his GP as healthy : He ll look at the other what are they called? He ll look at like a you know, like, what do you call it? Healthy ways? Not straight away give you medication. He ll look for naturopath naturopath, yeah, he ll look for like naturopaths and, like those and say, We ll see what the naturopath says first, and stuff like that. (AJ, 2009) UM, for example, a client of an inpatient drug and alcohol service describes this in the following way: I ve spent a lot of time with psychologists, I found they worked better for me than psychiatrists because I didn t want to use medication, I didn t feel that I had a mental disorder, um I needed a psychologist. (UM, 2009) UM situates her apprehension around prescribed medication within the context of having substance use issues as a primary concern, but also the desire to discuss her thoughts and feelings contributing to the substance use. Medication as a challenge to this discussion is echoed in the expressed past experiences of EK, also a client of an inpatient drug and alcohol service: Effective approaches 72

73 I guess most of the services in the past they just sort of lock you up, make sure you can t go out for the time that you re in there, throw you some medications and things like that and that s it. There s no delving into anything trying to find out what the problem is. (EK, 2009) Challenges while taking medication Many clients spoke of the varied challenges they experienced while taking prescribed medication. DD for example, a client of an outpatient mental health service, described the challenges and side-effects he faced while adherent to medication prescribed for what he described as anxiety and paranoia: I put on a lot of weight. The medication I had to take the first time, I think it s, Risperadone, or Risperdal; that made me eat a lot and put on a lot of weight, it also made me very tired, I didn t want to get up and it, like I had no motivation to do anything at all, I just wanted to sleep all day. (DD, 2009) For other clients, adherence and non-adherence to the prescribed medication mediated their experiences in profound ways. For LH, for example, one of his main issues was with the hospital. I refused to take my medication and they refused to feed me (LH, 2009). In other clients narratives, the prescribed medication exacerbated their mental health issues. OS, for example, said, I didn t stick with the medication either [pause] at that time. It was making me feel worse than [clears throat] what I did to start off with (OS, 2009). Yet for others, it was non-adherence to the prescribed medication that led them to a hospital admission. AJ for example, spoke of his experience: I stopped taking my medication and I was getting unwell. I stopped taking my meds and when I don t take my meds I m well if I like if I get into an argument I get angry and things like that. But I m alright now, I ve gotten over it I m just back on my meds and just taking them morning and night. (AJ, 2009) Other clients reflect upon their hospital experiences in a different way. BR, for example, an involuntary client at an inpatient mental health service, talks about her current experience: Oh, I just want to leave. I ve been here 6 weeks now and they still want me to stay on. It s just too long for the tax payer's money. I was normal a month ago. I m normal now and I can take my medication by myself but they don t trust that I will. So they re getting an order or something. (BR, 2009) BR spoke of how she had been admitted to that facility as a voluntary patient, but had subsequently become involuntary. BR saw here adherence to the prescribed medication as a way of leaving the facility. Another client spoke of being well enough not to need medication as a way of achieving his goals. OF said, I just want to get off medication so I can join the Defence Force. I want to get a job with the Defence Force. So that s my goal, sort of... (OF, 2009). For many of the clients then, challenges while taking medication centred on their experiences of the consequences of adherence and non-adherence, especially as this may have an impact upon their personal freedoms and goals. Combined pharmacological and non-pharmacological approaches: EK talks about this in the context of the detoxes and rehabs he has been to in the past relative to the service he is currently attending, where drug and alcohol and mental health issues are discussed in therapy sessions guided by the models of cognitive behavioural therapy (CBT), and Alcoholics/ Narcotic Anonymous (AA/NA). The importance of a combined approach to therapy that includes Effective approaches 73

74 pharmacotherapy is echoed in the narratives of the workers. This becomes especially important in the context of the client group of this study, who experience both mental health and substance issues, and as seen in the quote below, is highly connected to the recovery and aftercare process. FT, for example, who works in a community-based mental health support service, says: What really makes me angry is that they don t look about giving that person a holistic approach to the problem. That means they take her to hospital. They put her there, they observe her, they try different drugs until with one of them, the person seems to behave appropriate. Okay this person behaves appropriate. Let s release her into the community. (FT, 2009) FT is here talking about her experiences with a client who had exhibited acute symptoms of psychosis and is largely questioning the efficacy of inpatient pharmacotherapy in the absence of any complimentary approaches. Running alongside this however is the narrative of one of the workers who expresses the opinion that post-discharge care is extremely important in maintaining the recovery process. BT, who works in an outpatient mental health service, says: This is going to sound conceited but when they have blind faith in the system recovery is so much easier because families aside, just looking at clients, they re pretty traumatised by what happened in the main inside and judgment is poor and stays poor for a long time. It builds very, very slowly and so if you expect that insight will just you know, fall into place, post discharge in hospital so that they take their medication on their own, etcetera, etcetera. Not going to happen. So their faith in us, our ability to engage and build a rapport and get them to take medication because we re telling them this is going to help them improve, it s probably the best strength they can offer. Because insight and judgment doesn t come so, it kind of sounds conceited but their faith in us and our ability to engage them is probably the biggest strength. (W: BT, 2009) BT is here talking about clients referred to her service after discharge from an acute mental health inpatient setting. Pharmacotherapy s role in coming off a substance Some clients spoke of the challenges they had experienced when trying to come off, or quit, illicit substances. BS, for example, compared his experiences of trying to come off heroin, among other substances, in the country from which he had migrated. In that country, medication had not been available to him, and when asked about the different experiences he had in Australia, he said: A lot of difference. The services over here is really good. Over there is not proper systematic thing, not systematically run. It s not lack of, what s that, lack of facilities and all that thing, like medication, you know, because when I went to, the one I went in the rehab, they used to give no medication, nothing and it was very hard for me to quit over there. So I quit that one and I came back home again and again started using and slowly I, yeah. And over here is really good, over here I think it s, I haven t been in to any rehab but I ve heard from people over here is really good. Yeah. (BS, 2009) As he describes it, BS s experience of pharmacotherapy was that it had been an ally in coming off multiple substances. Experiences of pharmacotherapy for substance use, and largely in the narratives of eleven of the clients of this study, for opioid use, also appear. In the experiences of the clients, this approach too has its challenges. For GS and BN for example, methadone was placed in the same frame as illicit substances when they talk about coming off. BN says in relation to his aims of his current service access, I was detoxing off the methadone, heroine, pills and pot (BN, 2009). Effective approaches 74

75 GS discusses his experience of coming off methadone in the context of the difficulty he has found staying abstinent from cannabis: But the funny thing is I ve come off heroin, I ve come off methadone, I ve come off speed, come off crystal and it s sort of a week later you re fine. With the pot it s not so much your body aching it s your head that runs around and makes it really stressful. (GS, 2009) For some of the clients, their experience of methadone was complicated by their use of cannabis. CM, for example, was exited from a methadone programme because his urine samples showed he had been using cannabis. At the same time too, CM connects his mental health experiences with the experience of methadone clinics: I think that maybe more effort should be made when people go...to get, you know, help with an addiction or at a methadone clinic that mental health should be looked at a lot more (CM, 2009). In some senses too, the more holistic approach about which CM speaks is echoed in the narrative of MA, a client of a methadone clinic, who describes the challenges she experiences around the service she attends: And if you re on methadone and you re coming off the streets into private housing and things like that, you can t just be abandoned once you get in there, and they do (MA, 2009). While MA talks in a largely positive way about her current service experiences, the lack of aftercare appears frequently in her narrative. Other clients mention structural difficulties around methadone clinics, one in particular identifying coming from a country that does not have a reciprocal agreement with Medicare as an impediment to accessing methadone services: If I was an Australian I could have got into some other organise [organisation] instead and got into Methadone but because I didn t have Medicare and things so I couldn t get over there, so I got it in [service name] then I got Methadone. (AS, 2009) The service to which AS is referring does not require a Medicare card for access and operates on a drop-in basis. For some of the clients, narratives around pharmacotherapy s role in coming off a substance merge with their narration of their mental health. For TO for example, a client of an outpatient drug and alcohol service, her experience of substance dependence and mental health issues were so entwined that medication for her mental health issues became part of her normal life, and supplanted the other substances she was using: Developing, like, a normal lifestyle when you ve used for so long your whole life s revolved around using and you ve got to live a normal life. I found it really hard to get the right medication for my mental health, so that I m stable. (TO, 2009) Dependence on the prescribed medication Dependence on prescribed medication for both mental health and substance use issues was also discussed by the clients. MA for example, reflects on her experience of being admitted to a hospital because of intentional self-harm, and the aftercare provided by her local general practitioner: But they [the acute hospital-based psychiatric ward] put me on heavy medication and that was all right but I was addicted within a short period of time, and my GP was very generous with pills. [Laughs] He s not around anymore, so I can t get him into trouble, but he was very generous. So I had a Rohypnol addiction, so that helped me get my head together actually. The Rohypnol really did help, but by the time I realised how addicted I was, I was on like 15 tablets a day. I know, it s a lot. He didn t even warn me, to what I was doing, he d just keep writing, and because I was so young, I didn t understand what I was doing. (MA, 2009) Effective approaches 75

76 MA s experiences of medication for mental health issues are echoed in the narrative of NP when she talks about her experiences of getting help for substance use issues. NP says: But I did get medication from my doctor now. He put me on benzos. He said it was to try to reduce me from drinking so much alcohol, but they didn t work. I just become a benzo addict and an alcoholic [laughs], you know. Yeah, what do you do [laughs]? (NP, 2009) VY discusses her experiences with a psychiatrist whom she felt had helped her, but ultimately, the outcome with the medication prescribed was the same - in her experience, VY had become dependent: I mean my medication worked but it made me highly addictive, addicted, it made me an addict for God s sake. So I suppose you could say that didn t work... (VY, 2009). For these participants, the common theme was a dependence on the medication prescribed for their mental health and drug and alcohol issues. The significance of continuing care In the narrative of the clients, the context to which they were returning after their period in detox or rehab had an effect on how they saw the likelihood of relapse to substance dependence. For GS, for example, in his experience, a plan for after detox was needed to prevent relapse. In his experience, this did not happen. GS says, But see most people doing a 7 day detox will go back to it because they re going back to the same environment and there s no exit plan (GS, 2009). GS sees this as a possible outcome of insufficiencies in the acute mental health care process, and relates it directly to the prescription of medication in this setting: There s no um, you know, because they re going off their heads and that, they don t actually say, well this is the problem we ll fix it, they just lock them up and charge them. They get medication, get out and do it again. (GS, 2009) CM, a client of the same drug and alcohol inpatient rehabilitation service, contextualises the likelihood of relapse, in the absence of aftercare, in a slightly different way. He talks about the impact of the friendship circle from which he comes, and how this might influence his own relapse: Yeah, I won t be able to go back to that circle. Most of my friends have got either drug problems or mental problems pretty much all of them actually. I can t think of one of them that s not on some sort of medication for mental health issues. But I can t think of one that s getting counselling either. They all they re all on drugs, but they just see the doctor for that, which I ve always thought was strange...they re on Seroquel or antidepressants or antipsychotic. They get no other help from anyone else, just they re GP. (CM, 2009) Significantly, CM connects the likelihood of his own relapse with the aftercare experiences of his friendship circle. CM s experience seems to imply that as his friends receive only help from the general practitioner, that they continue to have drug and alcohol and mental health issues, the converse being, as implied by CM, that other forms of help may have assisted in preventing relapse. The role of non-pharmacological approaches When clients spoke about the non-pharmacological approaches that they felt helped them, much of the narrative rested on approaches in which the clients were able and encouraged to discuss their substance use and mental health issues. For example, DD, a client of an outpatient mental health service described how talking to a Psychologist had helped him manage his cognition: Effective approaches 76

77 I ve talked to [Psychologist s name] about my brain, she s the Psychologist and she sort of helps me set things out, like straighten things out the way I think about it and the way it s sort of easier to think about it, or the way I should think about it and try and change my perspective on a few things. (DD, 2009) Another client of the same service also spoke about how the discussions he had had there helped in managing his mental health issues. BM contextualised this within a narrative of a more acute phase of his mental health: It was helpful like they did mindfulness and all this stuff, like all this stuff, but because of the way I was I couldn t process it and I couldn t understand it. But I ve been recently when I do - over at [service name] I do mindful stuff, now I understand it because I m not so messed up. That would have been helpful but I couldn t understand it. (BM, 2009) BM had described how he been admitted to hospital with psychosis at sixteen years old after smoking cannabis on three occasions. When discussing this experience, he also talks about his initial experience of non-pharmacological therapy: I hated it when I was a kid I absolutely hated it but yeah, I had to go. It was just the idea of having to go and talking about all my feelings and explaining everything but yeah. Then I started getting used to it and it kind of really helped me. (BM, 2009) For BM, then, non-pharmacological approaches had over time helped him with his substance use and mental health issues. Other clients characterise these approaches as a way to alleviate negative cognitions and feelings. NR, a client of an inpatient drug and alcohol service, states: Yeah one on one session allows me to get crap off my chest and all that and it helps me to retrain and refigure out what I m going to do in life when I leave outside of here (NR, 2009). The role of mental health diagnoses Some of the clients spoke about the role diagnoses had played in their experience of getting help with substance use and mental health issues. One client from an outpatient drug and alcohol service, outright rejected the diagnosis she had been given, and spoke of how this had affected her therapy experience: Then two [Psychiatrists] in [name of suburb], one was absolutely useless, talked about his holidays in Tuscany all the time and depressed me even more. He told me I was Bipolar, which I m not, and I now have a psychiatrist that I m very happy with that works more on hypnosis and self-help and that sort of thing. (VY, 2009 [emphasis ours]) In VY s retelling of her experiences, the perceived incompetence of the therapist was confounded by a diagnosis with which she disagreed. For others, it is the labelling process involved in the diagnosis that may have an effect on their therapy experience. OS, a client of the same service as VY, spoke about the diagnoses she had been given: Yeah all right, I don t mind telling you. Bipolar and borderline personality with sides of schizoaffective. It s funny cause my GP calls it schizoaffective and my Psych calls it [long pause] borderline [long pause] and there was the issue of Stockholm syndrome that was bought up as well. (OS, 2009) OS questions however categorising people according to the labels attributed to such diagnoses: Effective approaches 77

78 I think basically to treat everyone as an individual and everyone s situation individually. It s not a category of [pause] psycho, schizo, junkie [long pause] this person s made up of 100 different things. (OS, 2009) Another client of the same service describes her therapy experiences, and contextualises them with the way she narrated the experience to herself: Well, I still had depression and anxiety, so I was running away from that, psychosis. I sort of, well because I was in a domestic violence relationship myself. So I was always looking for, Hey, guess what, I m bipolar, that s why I am the way I am, I was always looking for that, but I ve got the all clear now from the psych[iatrist] that I m actually quite normal, but I just got depression and anxiety in which I m getting treated. (DQ, 2009) DQ infers that because the Psychiatrist has given her the all clear regarding her psychosis and bipolar disorder that she is now normal, but is still in non-pharmacological therapy for drug and alcohol issues, as well as pharmacotherapy for depression and anxiety. In this instance, the psychiatrist s diagnosis has been very powerful in shaping how DQ has experienced therapy, and the ways in which she talks about her experiences. Still others expressed an alienation from therapy as a result of no defined diagnosis. KC for example, a client of an inpatient drug and alcohol service, had had many service contacts even though he was very young and attributed this in part to having a few problems and nobody seems to be able to work out what they are (KC, 2009). KC goes on to say, Still to this day, nobody has been able to work out what s wrong with me (KC, 2009). Skills building and planning Groups and training courses featured prominently in positive narratives around therapy experiences. Groups in particular were, in many of the clients narratives characterised as a way to stay busy and a diversion from substance use. Often too, it was the variety of groups that was seen as a positive aspect of therapy. AJ, for example, a client at a residential mental health service, says: [We] actually had groups, like all day long. Like, you had four groups or something a day or five, or four, one or the two. And I found it really, really like, really worked. All the boys were all they were keen to do the groups and stuff, so it was pretty good. one was about drugs in the morning, like drugs, what drugs what they do to you and stuff, and you had like a session like an art session, and then you had like a free period where you got to in the pool or you got to just play games and muck around. And then in the afternoon, they had another drug talk and then that was it, you had dinner and that was it. (AJ, 2009) Other clients too spoke about experiences of teaching and learning during their therapy experiences. SJ for example, a client of an outpatient drug and alcohol service, compared two service contact experiences, a previous experience of an outpatient drug and alcohol service, and her current experience: This service [long pause] is the only service that I have really found that has met my needs. The drug counselling that I went to, it was more like he d lecture me, it was more like I was being lectured, not listened to and taught, where they re really teaching us here. (SJ, 2009) In her narrative around the current experience, SJ expresses the areas of concern for her and how they are managed in the context of the current service: I would have preferred to have been given classes like I ve been given here. The understanding of what actual drugs did do to you and how it Effective approaches 78

79 destroys your body, your mind (SJ, 2009). Another client of the same service, VY, expresses how important the planning she is presently undertaking at the service will be for her once she stops attending: It s when I get out of here that frightens me. I m desperately trying to get into a TAFE course into after-care here two half days a week and then a job hopefully and then an AA meeting on the weekend and my psychiatrist once every month at the moment, then once every two months. (VY, 2009) VY contextualises this within the planning activities that she and a worker from the service are undertaking. Learning, therefore, skills development and planning for the future were key elements in the narratives of the clients. Flexibility and sensitivity Flexibility in service practice emerged as having a positive effect on the clients experiences of therapy. HW, a client of an outpatient drug and alcohol service, says:.even in and out of addiction, I ve ran my own race my whole life. So the flexibility that s offered here has been sufficient for me to feel comfortable and nurtured and accepted. (HW, 2009) In narratives of the workers this flexibility was re-framed as a process by which as many options as possible were offered to the clients, including being referred on to the appropriate service. DV for example, a worker at a community-based health centre, says: [I] offer choices a lot and explain why I m offering them cause I don t want to be in the situation where I m telling them what to do you know that s not, and I will try and explain why I don t want to do that and why I don t think it would be helpful to tell them what to do. So I guess, yeah, I spend more time with that you know they might be more comfortable going to see say the Psychiatrist who might tell them what to do. (W: DV, 2009) Other workers expressed an intersection between a flexible and individualised service and nonjudgmental service provision. Worker KC, for example, a community-based mental health worker, attributes the satisfaction of the clients of a particular drug and alcohol service to this model of service delivery: I think the other thing is, they re just very non-judgmental and are quick to recognise that there might be specific needs for specific people (W: KC, 2009). Another worker, MN, who works in an inpatient mental health service, describes the effect of the personal approach: I have seen like someone that s really on the urge of wanting to go out and drink and take drugs, and have seen a worker actually sit them down and calmly try and talk to them and try and get them to see, you know, using drugs at this time is not the possible best solution. (W: MN, 2009) Both workers and clients attributed positive experiences of therapy to flexible, individualised and personal service delivery. Effective approaches 79

80 Results - Interpersonal aspects Empathy Empathy featured prominently in the narratives of the clients of drug and alcohol and mental health services and was discussed in a variety of contexts. For some clients, empathy was described as significant from the very first contact with services. QM for example, says: If a person comes in and they don t feel that they got some empathy and some support in their first contact, I don t think they re likely to come back. That s why I never followed it up after the GP, I just went away thinking, Well this person doesn t give a shit. (QM, 2009) QM contextualises this experience in consultation with the GP in which the GP would not refer him on once QM had disclosed he was experiencing mental health problems he associated with his cannabis use. By contrast, QM also spoke about his current experience, his first time in a residential rehabilitation setting. While at this service, he arranged follow up counselling with an outpatient service, and describes the counsellor s approach in the following way: Empathy and knowledge and commonality of experience: But just talking to him on the phone, he s the guy I was talking to has, seemed to have a real lot of empathy. I don t know if he s got a drug usage background. A lot of the staff here do which really helps because they can empathise, they can relate and you feel that you can relate more to them when they ve experienced the same problems that you have. But just talking to this guy on the phone, I m really looking forward to meeting him because he just had a massive wealth of knowledge and he was able to suggest things that you could do to relax yourself and work on your depression and anxiety without just saying, Do this, do that. It was very, I don t know, it s difficult to put it into words but they were really mild suggestions. They made a lot of sense. (QM, 2009) Worker empathy was also characterised by the clients in several other ways. In the experiences of the clients, the most helpful worker approaches were often described as the worker putting themselves in the clients shoes : Well, just be understanding, try, and be empathetic. Put yourself in their shoes and just relax, because like, [chuckle] it s such a stressful job (FW: 2009). In terms of communicating understanding and connecting with the feelings of the clients for example, a caring approach emerged as key. AR for example discusses the service he is currently attending in the following way: Well, for one, they [workers] got me onside by actually saying they don t just come to work because it s a job, they come here because they care and that was stressed to me quite clearly. They told me that they wanted to help me. (AR, 2009) This caring approach was presented by many of the clients as characterised by workers whom they expressed cared about more than just a wage. AR for example went on to say, As I said, they re here because they care you know, it s not, it doesn t pay that much, you know (AR, 2009). KC described his experience with the service he was currently attending in the following way: The fact, I know it s just a good place. It s good surroundings, good people, they actually care more about stuff, like other than what s going into their wallets at the end of the week. If you re having a bad day, if you re having a hard time, they ll sit down and have a talk with you. (KC, 2009 [emphasis ours]) Effective approaches 80

81 By contrast, ND, a client at the same service, described some of the less helpful experiences he had had in the past, and put these in the context of an attribute of the workers that they really liked their jobs: cause some of the people don t just listen. You ve kind of really got to like your job too, especially in this business. If you don t like your job, you re not really helping anybody if you really think about it. (ND, 2009) Workers verbal communication as a way of demonstrating empathy was also discussed by the clients. UM discusses the service she currently attends, and when asked what advice she would give workers in the field, the following was offered: I think there s a way to speak to people and you know, so just to be very mindful where people have come from. Yeah, definitely and the respect thing which I think they do really well here, I really seriously do think that. But I think you should continue to be mindful and continue to educate yourself. (UM, 2009) This sense of worker awareness of the background details of the clients lives also fed, for some clients, into a discussion about the workers own self-awareness. DR for example, when asked the same questioned said that, in his experience: I think they [workers] have to be aware. Maybe ask themselves what they re doing in that sort of work environment in the first place and realise that you re going run into many people with that double up stuff, and not to be too judgmental. (DR, 2009) Honesty in communication, as it enhanced empathy, was also discussed by the clients as significant in helpful worker approaches. When asked what workers should know when working with people with mental health issues, BN advised: I just think honesty s the best thing, you know and if you re really going to give it a go, just be honest with what s going on with them and once mental health, then 10 times out of 10 that people will listen and be your best friend, you know. (BN, 2009) In sum, many of the clients described how, in their experiences, feeling that the workers understood and connected with the clients feelings was an important aspect of effective approaches to the clients substance use and mental health issues. One further point was expressed by some of the clients the effect that this empathetic approach had, in their experiences, on the workers. Two clients expressed this in contrasting ways. When QH, a client of an outpatient drug and alcohol service, was asked what advice he would give to new workers, he said, Don t get your heart, put your heart into it too much, because then you get hurt (QH, 2009). Another client perhaps illustrated this point when he related his experience of the departure of a client of an inpatient drug and alcohol service: [worker name] actually cried yesterday when [client name], I mean my mate left, so you can tell he s got the heart in it (ND, 2009). In some ways then, ND s experience is evidence of the significance of an empathetic approach by the workers, and the effect this empathy can have on both the clients and the workers. Shared knowledge Shared knowledge between workers and clients was narrated as helpful by many of the clients. KW for example, a client of an inpatient drug and alcohol service, discusses this in the context of worker approaches he found most helpful: Effective approaches 81

82 and basically the best thing I find is the best workers to talk to for me, is the workers who have been through what I ve been through. That s basically what, what people need is, what people that have been through it you know people who know what it s like to be in the gutter, to know what it s like to have an abuse, to know what it s like to be mentally and physically abused at a young age or being bullied you know what I mean; and basically that s what I find. (KW, 2009) NB, a client of the same service as KW, contextualises his experiences within a discussion around mental health issues that he reported to share with one of the workers: he was very similar to me with anxiety and that. That s why we just sort of, he can, yes I can see me in him and he can see that I m similar to how he is. But it does, it s a great help if they have been through it, because we got to the point where I could tell the ones that hadn t been through it, and a lot of them were just trying to positive self talk me and I could just pick it out. (NB, 2009) For NB too, age, and by inference experience, were also elemental to worker approaches. In his experience, he was not alone in thinking this way: Well not so much being told what to do. I think mainly they have a problem with, How is this person going to help me when they re so young? And when they haven t been through it. I ve heard it a few times out there the only problem I have is, sometimes I feel like I m being treated like a child, and it s being enforced by children. (NB, 2009) Some of the clients discussed commonality of experience, and how this may affect the worker s knowledge base: You don t understand unless you ve been there. I suppose everyone s got a story, everyone s got issues and all that sort of stuff, but until you ve been locked in to drug addiction, you got no idea of what sort of impulses and feelings and stuff run through your head. (CA, 2009) Worker knowledge attached to commonality of experience was pivotal to helpful worker approaches in the narrated experiences of some of the clients. KW for example, described an approach that in his experience would not be helpful: That s basically all I m gonna say, is that it all comes down to trust and your knowledge and the worker s knowledge, it all comes down to their knowledge. Like if I m, if I m sittin' in a room with a worker and they haven t used drugs, they haven t used alcohol, they haven t suffered depression, they haven t suffered anything that I have suffered in my life (KW, 2009) Shared cultural and linguistic diversity also affected clients experiences of approaches they found helpful. One client, WW, said for example, I like [service name] because the lady s [case worker] Greek Cyprian, and she understands (WW, 2009). WW goes on to describe her current experiences in the following way: They [treating psychiatrist] don t understand. And I m talking to an [different cultural group] doctor. They don t understand. They re by the book...it s just the understanding of the morals and the way that other people in ethnic backgrounds have grown up. Because being [different cultural group], they understand their one, but why can t they not understand our way. (WW, 2009) Effective approaches 82

83 The significance of shared cultural and linguistic diversity is echoed in the narratives of some of the workers. A worker in a drug and alcohol service related this particularly to the younger client group: I guess trying to find staff with different backgrounds and you know, different diversity I think is really beneficial for the young people (W: UW, 2009). Another worker from a community-based mental health service used an example of knowledge about cultural and family norms in linking shared knowledge, concluding that: I think it is very important to be seen by a person of similar background (W: FT, 2009). EF, a drug and alcohol worker, cited an example where an in-house training session was organised for generalist drug and alcohol workers to share knowledge about the needs of a particular CALD community in relation to substance and mental health issues. Shared knowledge therefore was narrated as significant in the experiences of both the clients and workers. Non-judgmental approaches The importance of non-judgmental approaches was prominent in the narratives of the clients and the workers of drug and alcohol and mental health services. These approaches were discussed in a variety of contexts. Judgmentalism around co-existing issues was discussed by many of the clients. QM for example, discussed the judgment he perceived a GP had made when he sought help for coexisting cannabis use and depression: I think it was just the drug aspect as well. I don t think the GP had a real understanding of the link between that and mental health or maybe they were thinking that if I was using drugs there was no point in getting psychological help because the usage of drugs were just perpetuated. (QM, 2009) QM discussed how he was aware that GPs could provide referrals for drug and alcohol and mental health services, but described the consequence of talking about his co-existing issues with the GP: Yeah well I knew the GPs could do referrals but this particular doctor, as soon as I said drugs just didn t seem to want to have a bar of it (QM, 2009). Some clients described judgment by workers around relapse. MA, a client of an outpatient drug and alcohol service, described her experiences with an opioid treatment programme: When I was getting off alcohol, if you were first time in it, they were very helpful, but if you relapsed or anything like that, they were very hard on you, and they didn t really understand. They were just like, If you don t do it then we re finished with you. (MA, 2009) A client of an inpatient drug and alcohol service describes his experience of attending a service similar to the one MA attended in the following way: The thing with the drug and alcohol clinics, the government run ones, it always felt like they had a quota to fill and the more they got out the door, the better it was for them, the more funding they d get. Even with the counsellors, like I've only struck a couple of counsellors that sort of really give a shit, but at the end of the day, if something went wrong, they d judge you just the same as anyone else on the street, which is heartbreaking, you know. You sort of think, These people are supposed to be here to help me and they re not. (CA, 2009 [emphasis ours]) Effective approaches 83

84 Other clients discussed the judgment they had experienced, especially surrounding their co-existing issues, by practitioners: Also my addiction, getting judged. Cause you know, they just look down from the counter and, Oh yeah, they see addiction on there and mental health issues, Psychiatrist notes, put it to the end The lower grade, straight up, the scum of the scum, gutter trash. And of course, if you ve got mental health issues, basically worthless. (EP, 2009) For some clients, judgmental attitudes were experienced in connection with the feeling that worker really did not care. AR for example, said: I was really concerned, I thought she didn t care, you know, here s all these other ones saying they care and this one wouldn t look me in the eyes, and she would look down and she would fucking look over here, you know what I mean. (AR, 2009) For others, their experience of judgmental attitudes was contextualised within being looked down upon and patronised. This was stated explicitly by NF, a client of an inpatient drug and alcohol service: They re well trained and that its just up to the individual, but I guess sometimes it looks like you re being looked down on by the workers (NF, 2009). TP, a client of the same service, goes into further detail, and how these attitudes have influenced his experience of the service: The workers, the people that are actually paid to be here, [laughs] they think we re fucking idiots or something. I don t know if the other people pick up on it but I feel like we re being some of the time pretty patronised.i don t really talk to the workers cause I don t really like em, yeah. They re alright but they re just [long pause] I dunno, I just get the feeling they think we re idiots or something. (TP, 2009) Another client described a different experience with workers, that is in some ways connected however with the experience of an uncaring and unempathetic approach: Every now and again we d have a counsellor, we d sit down with a counsellor and they just sit there and throw a bunch of cliché s at you until they found one that broke you and you d start crying and everything, and they d go, yep that s it, that s the one, that s your problem. (CA, 2009) In a similar way to CA, DR also recalls one of his experiences with a worker: I can t remember her title, but she was some sort of worker there and the way she delivered her information I just thought, and her information was just appalling, be enough to drive somebody who was nearly at the edge, right over the edge. (DR, 2009) DR contextualised this experience in a time when he had sought help for an ongoing mental health issue and had found the worker whom he had approached a worker in a mental health service. For DR, rudeness was one issue, but domineering behaviour was something else altogether. In another instance he recalls: Like I can put up with peoples rudeness, that s fine, but she was just so fucken much of a standover merchant I thought, You re not going to do this to me. (DR, 2009) Many of the workers in both drug and alcohol and mental health services also discussed how, in their experiences, a non-judgmental approach is important in outcomes for the clients. For one worker in an outpatient drug and alcohol service, it was the culture of the organisation that fostered this approach: This service is fortunate that there is an ethos of non-judgmental behaviour. I think clients Effective approaches 84

85 do feel welcome to come here (W: EM, 2009). When discussing what she thought the service she worked for did well for their clients, drug and alcohol worker KC said: I think the other thing is, they re just very non-judgemental and are quick to recognise that there might be specific needs for specific people. So if we ve got someone with an Islander background, we had some Islander guys in, young fellas in a while ago, very quiet people, you know? And we didn t understand much about their cultural background; you don t sort of do this or you do that or So accessing, sometimes it s about accessing like community elders you know, for them to have a chat to or role models for them to have a chat to. (W: KC, 2009) Another worker in a drug and alcohol service spoke about non-judgmental approaches in concrete terms too, and in the context of obviating shame. This worker added a cultural dimension to this approach: I impressed the families so much, I ve really poured in my heart and soul to work with this kid, that I got invited to their place because it was the mother s birthday. To the house in [suburb name] where they make this traditional Vietnamese banquet and we just sit around and after that the father came and sat and had a beer and started talking about his progress with his son because of what I said to him and stuff like that. It was really nice and then he doesn t have the shame talking to me because he realised that I was the professional talking to him. So just to get that rapport is vital. (W: KW, 2009) A worker at an outpatient mental health service also spoke about judgmentalism from a different angle, but also incorporated his own experiences: I suppose workers often as much as we try to be non-judgmental, we all judge people and we all look at a name of an Australian-born Chinese, but even though people can still look at a name and go and they all pre-judge it. That s just the thing. (W: AT, 2009) AT spoke about this in the context of making and receiving referrals, and that, to a degree, in some instances, workers might form a picture of the client before actually meeting them. It is of significance therefore, that AT is aware and self-reflective of this, pointing to the possibility that non-judgmental approaches are seen by workers as key to the outcomes of clients. Group cohesion In one outpatient drug and alcohol service, many of the clients spoke about their experience of being members of a cohesive group, and how important this was in the outcomes of attending that service. HW describes the bond between clients that he has felt at this service and how important this has been in outcomes for him: And if someone s off for a day, we re so worried that they re busted, that when they come back and say they re sick we re relived, you know. And it s really a universal bond. Age, sex or religion which is in our thing we read before group, it really isn t a consideration. We ve got a gay guy there and I treat him like my son, you know. No, we re here for the same reasons and there really is quite a bond in [service name]. I love it. I feel, as part of my recovery, because I was so isolated in my addiction that this feeling of belonging to me is so important, that it is just fantastic. (HW, 2009 [emphasis ours]) Another client at this service characterises her experience by likening the clients to being members of a family: We just seemed like a big family, it doesn t seem like that anybody was singled out by virtue of their race or colour or whatever or culture (VY, 2009). For another client, it was the realisation that Effective approaches 85

86 he needed to be honest and open with his fellow group members that he perceived led to positive outcomes: I ll be honest with you, I ve told everyone there, all the group and that, I used to, I feel like I can pull the wool over everyone s eyes, again like I had been doing for the last 20 odd years. About three weeks into the programme, the penny dropped, something changed and I realised my life was starting to turn around, if I wanted it to work it was, things were happening that I, opportunities were coming and where they never did before, well they were maybe there, but I was too smashed to realise or I just let them slip and go by. (QH, 2009) Common too among the narratives of the participants from this service was an expression of equality based on dependence; that is, the clients spoke about their fellow clients as peers, regardless of which substance or substances had prompted them to attend the service. QH for example said: But the interaction in there, I think we re all equal and because we ve all got our own addictions I suppose, there s no one s ever singled out or anything like that (QH, 2009). VY attributed this sense of equality to the ethos of the service: And here unequivocally, absolutely but the first hurdle that people have to realise is if they re an alcoholic they re no better than any of the other junkies that walk through this door. Okay? We re all the same. Our drug is just as bad as heroin or anything else and that s the first thing they drum into you. (VY, 2009) Discussion Among the narratives of the clients, the roles of both pharmacological and non-pharmacological approaches feature prominently. The interactive relationship between the two, as expressed by the clients, accords with the vast literature, reviewed in a study by Wolf and Hopko (2008), on combined approaches to mental health and substance use issues. The role of diagnoses in how the clients narrate their experiences of therapy features too in studies related to the perceived need of health care for anxiety and depression (Prins, et al., 2008). In a review of the literature around barriers to health care for culturally and linguistically diverse communities, Scheppers et al. (2006) identify a legion of possible barriers but suggest that while some may be tied to ethnic minorities (Scheppers, 2006: 325), the barriers are all tied to the particular situation of the individual patient and subject to constant adjustment (2006: 325). Augmenting this however, suggest Schraufnagel et al. is the underutilization and poor quality of mental health care in minorities due to less-than-favourable illness and treatment beliefs that affect adherence and outcome, stigma, clinician failure to engage the patient (Schraufnagel, et al., 2006). In combination then, the literature suggests that pharmacological and non-pharmacological approaches may have a synergistic relationship, and that client beliefs about their mental health and substance use issues have an impact on the effectiveness of these approaches. Additionally, for culturally and linguistically diverse communities, this effectiveness is shaped by this diversity, but is also related to the individual context of the client. In the narratives of the clients of this study, these findings are largely borne out in the ways in which the clients talk about the effectiveness of flexible and sensitive approaches to therapy and the narrated significance of skills building and planning for the future. Non-judgmental approaches of workers and group cohesion featured prominently when the clients discussed their experiences of attending services for their drug and alcohol and mental health issues. Effective approaches 86

87 In the experiences of the workers in these services too, the significance of non-judgmental approaches to service provision also featured. In addition to the previous discussion on effective approaches, here the salience of empathy is discussed in relation to the experiences of the clients. Many clients also discussed the significance of feeling that they shared experiences with the workers, and some clients expressed the importance to them that the workers really cared about their jobs, and indeed the clients themselves. Honesty too, from both the workers and clients, was described by many of the clients as a way of mutually understanding and connecting thoughts and feelings. The significance of empathy, as expressed by the clients, in effective approaches to drug and alcohol, and arguably mental health, issues accords with the literature on the importance of therapeutic empathy more generally (Beutler et al., 1994). James Bell (2010) discusses the significance of empathy, particularly in relation to approaches to drug and alcohol issues: The discipline of diagnosis and prognosis can easily be experienced by patients as not just lacking hope, but as being judgemental and objectifying. The resolution of this bind is the critical importance of empathy, of being able to see things from the patient s perspective while offering an informed, dispassionate perspective. In the addictions, more than any other area, empathy is of the highest importance in improving outcomes (Miller, 2000) (Bell, 2010: 16). In the article to which Bell (2010) refers, William Miller asks, Why does the interpersonal quality of empathy seem to make so much of a difference? (2000: 11). Later in the paper, Miller describes the therapist who engages the most effective approaches as characterized in terms such as humility, patience and selflessness (2000: 13 [emphasis his]). Using both Bell s (2010) and Miller s (2000) assertions as a foundation, it is possible to argue that it is the experience of empathy that draws the client into an effective therapeutic situation, in some senses facilitating a feeling of belonging. The importance of this feeling of belonging was apparent in many of the clients narratives, particularly around personal equality and integration into a trusting and secure social unit. James Bell talks about this feeling of belonging in terms of culture : Culture is affiliation, participation in a world outside of self, providing identity and purpose. For a time the addict subculture provides meaning and purpose for young, disaffected people. Social re-integration is recovery, whatever forms of affiliation employment, relationship, church that re-integration takes. (2010: 16-17) It is perhaps here that empathy as expressed in the experience of the clients has had its most significant effect bringing the clients back to a sense of integration within society more generally as seen in the many narratives around coping skills. Many of the clients described this re-integration process in the context of their aims for the future: regaining custody of their children, return to or gaining paid employment, gaining accommodation, and not relapsing for example. The narratives of the clients (and in many senses, workers) in this study provide support to understandings of empathy in approaches to drug and alcohol and mental health issues, and how this empathy can facilitate a reintegration process. Further investigation may be warranted in how this empathy and re-integration may look for people from culturally and linguistically backgrounds. For example, in 1997, Farnill et al. found that while training pre-clinical medical students in cultural competence improved the students capacity to work cross-culturally, there was no significant increase in their communication of empathy. In 2006, Meeuwesen et al. found that Dutch GPs showed considerably more empathy for culturally and linguistically-concordant clients. Given increasing cultural and linguistic diversity, further investigation could include investigating how empathy in drug and alcohol and mental health service provision is communicated cross-culturally. Effective approaches 87

88 While these narratives are an echo of the findings of Reid et al. (2001), it is perhaps timely that a focus is drawn to the individual contexts from which culturally and linguistically diverse clients of drug and alcohol and mental health services in an increasingly diverse society come, and how this may inform service provision. In some senses, a limitation of the present study is that despite much effort being taken to access CALD clients of services, it is possible that some of the richness of narrative from, for example, a client who required an interpreter, is not included in this study. In this study, an ethnospecific drug and alcohol service was approached, a worker there was interviewed, recruitment materials were prepared in the language of that service, and the research project was heavily promoted at the service. Interpreters were at the ready to conduct interviews. No interpreter interviews were achieved. The CALD component of the client and worker participants was high approximately half of all participants self-identified as having a CALD background, yet all interviews were conducted in English. Further investigation may lie in how to actually access clients for whom English is not the preferred language in order to more comprehensively examine how outcomes of different approaches are narrated by CALD clients. Effective approaches 88

89 1 Effective approaches 89

90 Significance of therapeutic language As part of this study, how the clients spoke about their experiences of drug and alcohol and mental health service provision was a key interest. In looking at the ways in which the clients narrated their experiences, it may be possible to uncover, in terms of therapeutic models, what works and what doesn t. In many ways, the aim was to see how much the clients knew about these devices, and how this may have influenced their decisions in getting help. The aim here was to examine the language used in describing the contact with services and how this may influence the experiences of clients from culturally and linguistically diverse (CALD) backgrounds. Method Typically, the rhetoric of the therapy was engaged when we asked the clients the following question: Was there anything that services you have been to did that you found particularly helpful? Largely, clients responses centred around cognitive behavioural therapy (CBT) and the rhetoric thereof, but the language of Alcoholics/Narcotics Anonymous (AA/NA) also featured prominently. The analysis therefore centred on how the clients narrated a sense of self-identity and self-esteem within the language of these two therapeutic devices. Further analysis was undertaken of the narratives that diverged from the CBT and AA/NA language, those that engaged talk of spirituality for example, in order to examine how the dominant therapy models may become problematic when engaging with CALD clients. Results General familiarity with the language and devices of therapy The significance of rhetoric around treatment modalities was largely confined to the narratives of the clients of drug and alcohol and mental health services (not so the workers). This would hardly be surprising given that for 49 of the 52 eligible clients, the service at which they were interviewed was not the first occasion on which they had had clinical intervention. What was surprising however was the depth of narrative around therapy and therapeutic language. QM, for example, had not used a drug and alcohol or mental health service in the past six months, yet could clearly account for the strategic direction of the service he was currently attending: They re moving away from the, not so old narcotics anonymous program of it being addiction is a disease and the analogy that they use is that you re allergic to your drug of choice and you have to abstain from it because the allergic reaction is that you just want more and more and more and it becomes uncontrollable... But they re moving more towards this CBT model, which deals with thought processes as opposed to just total abstinence. (QM, 2009) Presumably QM was apprised of the organisational model by the staff upon entering the service. What is curious however is the connection with the language of therapy QM seemed to have had, demonstrated in his familiarity with treatment modalities. Another client of the same service readily engaged therapeutic language by using the abstract acceptance rather than the verb: Significance of therapeutic language 90

91 Just probably staying clean, because after I left here last time was pretty hard to do, I didn t end up doing it, but mainly just acceptance that I do have a problem and I can t control it because if you don t admit that you can t beat it. (FW, 2009 [emphasis ours]) In many instances too, the role of the self came to prominence when clients reflected upon their experiences with therapeutic modalities. For example, the model of which QM and FW speak centres upon an admission to self that there is a problem, then developing the skills to individually manage this problem. As one client so emphatically stated: It s up to you whether you fuck up now or not. It s up to you (WW, 2009). Another client re-iterates this feeling, but with slightly more apprehension: I don t think I realised just how much I have to do myself (MA, 2009). As another client observed: there s probably a handful of people that can go, Oh yeah, I just quit, no worries I ll start doing this and that. You need to have progress, it needs to be a learning experience, and every day I ve been learning. (TM, 2009) TM also highlights another important therapeutic language: that mental health and substance issues are to be managed with skill development and maintenance of a routine. These were persistent themes in the narratives of many of the clients. For example, CM relates his experience of the cognitive behavioural therapeutic sessions they attend at their residential rehabilitation programme: Just explaining how my mind works when I m in addiction and why it causes depression and anxiety; how anxiety works, things like that, learning tools to deal with anxiety or stress; tools of identifying different when I m not all right. (CM, 2009) Another client at the same service described his goals for an extended rehabilitation programme using the language of skill development: I m going to learn self-control, discipline and um, it s like healthy body, health mind, healthy spirit; I m going there to learn that (AR, 2009). MA describes her decision to continue using the drug and alcohol service she currently attends with a view to prolong her learning process. She says, I m hoping they ll [the drug and alcohol service] take it a step further so I can get into education and different coping skills (MA, 2009). Many clients narrated their experiences with CBT, and in a range of forms, from mild ambivalence, such as expressed by CA: The CBT stuff seems to be it s hard, it s bringing up some old demons but it s something I think I need to do (CA, 2009), to glowing recommendation, such as expressed by EW: I m really enjoying this CBT that they do here at [the residential rehabilitation programme], I really find that I m more of a practical thinker and I can actually see what they re trying to do, I can understand it, you know where a lot of other models (if you want to call them) aren t so black and white, I find it hard to be able to grasp hold of something that I can t see or understand CBT is not like that, it s written on the board you can see what angle they re trying to take, I m personally getting a lot out of it. (EW, 2009) In some ways, these two comments reveal conflicting experiences with the actual processes of CBT. For CA, for example, CBT was a way of recognising and possibly releasing negative thoughts from, and regarding, the past, while for EW, CBT functioned as a tool for learning ways in which to organise his thinking and feelings. Planning in order to avoid relapse was a common theme and reflects EW s comments above about being able to see, literally, the strategies on paper. DD, a client at a hospital-based mental health service, says: Significance of therapeutic language 91

92 we re going to do today is we re going to write out a plan for your week like I would never of done that before, I would of done it for work but I wouldn t have done it for like home. So we wrote out a plan on what I m going to do, when I m going to get up, what I m going to do next and then after that, and all these activities that I can do, and that was good cause it sort of structured my day and it sort of gave me things to do throughout the day. (DD, 2009) The effectiveness of this planning process was borne out in FW s narrative: I was supposed to have a structured daily plan and keep busy and do things that I like, and as soon as I let go of my structure and daily plan everything fell to shit (FW, 2009). CBT/AA/NA and self-identity What is also significant about the relationship the clients had with CBT was the language often used when incorporating the therapy into their view of the identity. The language of therapy became the way some of the clients expressed their sense of identity. For example, CA, who was attending the same residential rehabilitation service that used the combined approach (as mentioned above), indicated that they had done a lot of research to find the right service for them, concluding that, the CBT and it s all about searching inside yourself and discovering self-identity and core beliefs and all that sort of stuff, which is why I'm here (CA, 2009). TP who attends the same service, even while expressing ambivalence about the value of CBT, engages its rhetoric to describe his situation: CBT s pretty confusing, yeah. I m more into the self-identity and the core beliefs and social skills groups, but the CBT, some of it you know, yeah, yeah, it s alright (TP, 2009). The similarity in the way both CA and TP narrate their self-identity in connection with therapeutic devices is striking at a service level, given that they attend the same service, but could point to the pervasiveness of this language more broadly. Subtly, OS refers to this when she discusses her experience of therapy: [Pause] no, to me what s not working is me. [Sighs] [Pause] me willing to deal [pause] with the reasons why for the substance abuse, me [long pause] being honest with myself, I suppose (OS, 2009) OS employs the language of therapy to describe how she feels about her identity that it is in fact her self, not the therapy, that is not working. CBT/AA/NA and self-esteem esteem WW, who attended an inpatient mental health service, related her development of self-esteem as a product of the therapy in which she had engaged: So I must admit being here has done me a hell of a lot of good. Yeah. Like, yeah, I ve seen myself differently now. I can actually because I was molested, I never actually looked at myself properly in the mirror and thought that I was beautiful, but I am. Yeah. Just, it s not my fault.you know, I m going to worry about myself now. (WW, 2009) Happily for WW, her experiences with therapy had brought for her positive change to her outlook. Now she can say she feels a bit sad, but not sad enough to cry because I can fix myself (WW, 2009). Significance of therapeutic language 92

93 Yet another client at another service narrates their personal revolution using the language of the therapy: I didn t have no self-esteem at all; I used to let people walk all over me. I was a people pleaser, said, Yes, when I really meant, No, said, No, when I really meant, Yes, and now I find I m taking care of myself which is fantastic. I ve turned my whole life right around and I m so happy that these people have given me a chance to change my life...about three weeks into the programme, the penny dropped, something changed and I realised my life was starting to turn around, if I wanted it to work it was, things were happening that I, opportunities were coming and where they never did before, well they were maybe there, but I was too smashed to realise or I just let them slip and go by. (QH, 2009) Many elements of the therapeutic discourse are visible in QH s account of their progress to wellness: the self-esteem narrative, the epiphanic moment and the agency of seizing opportunities. It is almost as if QH grasps their whole narrative of self through the language of the therapeutic language: It could of been easily to just slip and go back into relapse. I think it was, the challenge is the change of attitude. To me it was the change of attitude, I had a shithouse attitude towards life in general (QH, 2009). Challenges for therapeutic language and CALD When talking to the workers, it became clear that the total imposition of therapeutic language was not without problems, especially when taking into account cultural and linguistic diversity. One worker, when discussing using various therapy models with CALD communities noted, So as I said before, it s one thing to have, you know, those models exist, but it s another thing to engage in them (KR, 2009). KR mentioned this in the context of using traditional models such as CBT with his client group which was almost entirely CALD. Another worker, who worked in several languages other than English, also suggested difficulties in a rigid deployment of any particular modality: So the difficulty we have would be, my difficulty with that is that I m taught in a model where I m supposed to deliver a certain model and yet I know what they re trying to say, that this doesn t fit us. So then, I don t have any alternative. There is no alternative. (KW, 2009) Two other workers also questioned the unilateral engagement of the language of therapy, especially when working with clients from culturally and linguistically diverse backgrounds: I mean in terms of someone suffering from depression, things like counselling, the concepts, they re not translated because they don t, they re not used. So we don t have those words in many languages, we don t have the word counselling. Doing group therapy s a concept that, I mean if counselling is very foreign, you can imagine what group therapy is going to be like. So I guess in terms of that it s not a very, it s not receptive of the culture of the people attending. So again, it s very main stream focused. So that s been my experience anyway. (W:CA & W:BP, 2009) Clients too spoke about the challenges arising from the therapeutic model. These challenges were located in three connected areas. For one client from a CALD background for example, mental health was seen more as a spiritual thing : I don t know if that s so much cultural or more just my family, but like that mental illness is more related to, like, a spiritual thing and that if you re if you re praying and doing what Significance of therapeutic language 93

94 you need to then you won t be mentally unwell it means that I m less likely to tell them if I m struggling. (TO, 2009) For TO, then, the location of mental health within a spiritual domain runs in many senses against the dominant models of therapy, CBT for example, that suggest mental health issues can be faced using cognitive reasoning. This accords with worker KR s comments related to the CALD community in which he works:...within that particular CALD community, mental health is concerned is seen, sorry, as a spiritual issue not as a physiological, biological, sort of, medical issue (W: KR, 2009). Religion too featured in the narratives of some of the participants. For one client of an outpatient drug and alcohol service, it was against [his] religion to touch any drug (IK, 2009). Mental health issues too are sometimes spoken about as being attributable to a transgression of a religious code. One worker for example says:...and literally the young person has said to me the reason why they had schizophrenia was because they thought that they were bad person, because of their significant history with crime. With, you know their offending behaviour. So they thought that this was retribution from God for that. (W: KR, 2009) KR contextualises this comment within a narrative around the onset of psychotic symptoms as connected to a significant history with pot (W: KR, 2009). This too is put in the broader context of the normalised use of substances in the community at large: Their usage of any substance, including pot, has been characterised by what they do in the community, socially (W: KR, 2009). Clients also narrated the normalised use of cannabis within the family context. SJ, a client of an outpatient drug and alcohol service, said, Growing up I always thought marijuana was like, everyone done it. Because all my family done it I thought it was normal, I didn t realise pot was actually illegal (SJ, 2009). Models of therapy, spirituality, religion and attitudes to use all appear therefore in both the clients and workers narratives around substance use and mental health issues. Discussion The results of this part of the study in many ways suggest that the clients frame their whole-of-life experiences within the context of therapeutic language, at least while speaking about the experiences in a therapeutic setting. This framing is not limited to their experiences with drugs and alcohol and mental health. This is perhaps not surprising as, at the time of interview, all of the clients were attending services that used the devices inherent within therapy, CBT and AA/NA for example. Of significance in the findings however, was how the clients narrated their experiences almost without exception through the language of therapy, in many cases, right to the core of their identity. 4 What became evident in this study too, is that especially in working with culturally and linguistically diverse people, who have substance use and mental health issues, the diversity of experience is highly significant. Tensions exist here too. For example, how can cultural and linguistic diversity be recognised and accommodated when the system of healthcare itself is intrinsically Anglo-Celtic in its origin? Moreover, how can the terms and prescriptions of the dominant therapeutic language be 4 For a thorough discussion of the ambiguities around recovering identities, see Rafalovich (1999), Howard (2006), and recovery s ethical dimensions, see Kleinig (2008). Significance of therapeutic language 94

95 made meaningful across culture and language, and in particular, how will this affect the narrative each individual generates about themself? In this study, a limitation may be found in that all interviews were conducted in English, a language which for some participants may not be their first. Recommendations for further investigation would be pursuing interviews conducted in the first language of the participant, whether by interpreter or multi-lingual interviewers. In some senses though, the answer to the first question lies in a recognition of the socially-constructed nature of both the substance use/mental health issues as well as their treatment. In a study by Gorman and Huber (2009), the evidence-based assumption of the Drug Abuse Resistance Education (DARE) programme was criticised. While it was found that with a suitably sympathetic set of analyses, the DARE program might also be considered an effective prevention practice (Gorman and Huber, 2009: 410 [emphasis ours]), Gorman and Huber (2009) went on to suggest the relationship between the problem (substance use) and the solution (programmes like DARE) may not be as straightforward as is often claimed. This, say Gorman and Huber (2009), is largely due to the social construction of the problem and its solution: Sociologists have argued that the definition of a behavior or an activity as a social problem is determined to some extent on the claims-making activities of those who find the behavior or activity unacceptable (Spector and Kitsuse 1987). Thus, to varying degrees all social problems are socially constructed, and the content and character of these social constructs can change over time. The analysis presented herein, along with the critical literature that is emerging in the area of evidence-based drug prevention (e.g. Brown 2001; Gorman 2005b; Gandhi et al. 2007; Midford, 2008), suggests that social solutions, such as social problems, are also socially constructed (Gorman and Huber, 2009: 410) The following example may be useful in illustrating this point: one participant, a drug and alcohol worker in a service whose client base was almost entirely composed of one culturally diverse community, suggested that within that community, mental health issues were seen very much as related to the spiritual rather than the psychological (or medical) domain. The worker further suggested that using psycho-medical terminologies with this client group was alienating for the group as well as the individual experiencing the mental health issues. Another worker identified medication itself, when used for mental health issues, as often incongruent with the spiritual: And understandably, because everybody has a particular world view they come from in terms of how they perceive their current moment and if that is a spiritual world view then the medication doesn t fit in. (BT, 2009) In this context then, the claims-making of those who find the mental health issues unacceptable (that is, the treating medico, for example), overlook the spiritual dimension experienced by the person who has the mental health issues, their family and community more broadly. This brings us inevitably to the second question: by which means can the dominant models of therapy and their prescriptions be rendered meaningful across cultures and how will this affect the individuals self-constructed narrative about themselves? In the example above, the person experiencing mental health or drug and alcohol issues may on the one hand, narrate that they realise they have a problem and need the skills to overcome this problem. On the other hand, this person may narrate that they have a spiritual issue requiring a spiritual solution. It may be that at least in recognising the plurality of Significance of therapeutic language 95

96 these narratives, help for this person may best be provided, even with the dominant existing framework. Further investigation may lie in how this recognition can be embedded in the practices of drug and alcohol and mental health services. The results from this study suggest however, that an unquestioning application of dominant models of therapy may be problematic when working with people from culturally and linguistically diverse backgrounds. Significance of therapeutic language 96

97 Part III Structural issues In speaking about experiences of service access both clients and workers identified broader structural issues that affected the receipt of specialist care for CALD clients experiencing co-existing issues. Key themes included the capacity of the health services sector to effectively help people with co-existing issues and to accommodate the particular needs of some CALD clients. These results are summarised below. Significance of therapeutic language 97

98 Organisational and structural issues It is widely acknowledged that longer duration in treatment with a drug and alcohol service has a beneficial effect on the protective resources that can help a client in avoiding returning to problematic use (Laudet, Stanick and Sands, 2009). In addition, this effect may contribute more to long-term remission than does treatment oriented toward reducing or eliminating substance use per se (Moos & Moos, 2007: 52). For at least these two reasons attrition from drug and alcohol treatment services poses a huge challenge to the effectiveness of treatment (Laudet et al., 2009). When concomitant mental health issues and potential language difficulties are added to drug and alcohol issues, then the challenges faced by both the clients and the workers become even greater. Part of this study therefore, was to examine what it is about the system that is difficult to navigate for people who have both substance use and mental health issues. It was anticipated that the narratives of both the clients and the workers within mental health and drug and alcohol services might reveal in many ways the challenges they have faced with the system of health services provision. One of the aims therefore of this study was to look at the challenges associated co-ordination of services, the marketing of services and the availability of resources, especially for people from CALD backgrounds. Contrasting however with these challenges was an investigation of the attitudes, motivation and work of individual workers. These contrasting elements are central to this part of the report. Method Workers were asked the following questions concerning the challenges of operating in the mental health and drug and alcohol services system: What problems might clients from culturally diverse backgrounds experience when accessing health services? In your experiences what have been the difficulties in working with clients from culturally diverse backgrounds? Prompts sufficient bilingual materials, working with interpreters (access, training, professionalism of interpreters), worker s cultural knowledge and attitudes, gender, family attitudes and perception of treatment What problems might clients with comorbid cannabis use disorder and mental illness experience when accessing health services? In your experiences what have been the difficulties in working with clients who have a comorbid AOD and mental health condition, particularly in relation to cannabis use? The workers identified what might be described as foundational systemic challenges for people with either a substance use or mental health issue, which amplified if the issues were co-existing and if there were also linguistic challenges. Similarly, we asked the clients of drug and alcohol and mental health services about the challenges they had faced when first accessing services, and also the challenges faced while in treatment. The following questions were asked: What things have been challenging for you since you ve been getting help for your mental illness / drug and alcohol issues? Have you had any problems or difficulties at the services you ve been to? Organisational and structural issues 98

99 What difficulties have you had getting what you wanted out of being at a service? Did you have any trouble getting into a service due to having drug use problems as well as a mental illness? Do you think people with drug dependency issues and mental illness get the same access to services or help as people who only experience one or the other? From these questions we hoped to elicit narratives around the well-documented challenges people with co-existing mental health and substance use issues face when coming to, and remaining in treatment. (See Jané-Llopis and Matytsina (2006) for a systematic review of the comorbidity literature, but also Degenhardt et al. (2001) for literature around treatment outcomes.) Results Separation of drug and alcohol and mental health services As one worker in this study quite unaffectedly stated:...the system is not underpinned by any notion of co-morbidity and I think that that s the issue, and I just think poor service delivery for people, especially say with cannabis use who, and if they re linguistically challenged as well as another, and just another layer of crap they have to put up with. (W: EM, 2009) Overwhelmingly, when talking with workers about the issues faced by organisations and individual workers when assisting clients with both substance use and mental health issues, the notion of a ping-pong effect became clear. Indeed, many of the drug and alcohol workers in particular actually used this terminology. One drug and alcohol worker described their.great frustration with the ping ponging of these people between mental health and drug and alcohol services..., the possibility of linguistic difficulties and cultural differences aside: But I think on the ground that there s people that are in the too hard basket, you re mad or you re a drug addict and no one s seems to want to match them up. I m sure if you ve got language issues on top of that you just sort of beaten from pillar to post and I think that s appalling. (W: EM, 2009) Despite the somewhat colourful and sardonic language used by EM, the implications are clear: often there is incapacity both for the workers and the organisation to effectively help people with substance use and mental health issues. Another drug and alcohol worker situated some of the difficulties within the nature of the facilities themselves. When discussing the physical separation of drug and alcohol and mental health services, EF says: We re physically, geographically we re in two separate areas of the campus the Department of Health is drug and alcohol, and mental health, we ve got dual diagnosis projects, and you separated [the projects], like go figure, doesn t make any sense... (EF, 2009) EF does however provide recommendations to avoid people being admitted to the facility through the mental health sections without getting the help for their drug and alcohol issues: Organisational and structural issues 99

100 It would be good if you could get a one stop shop, if you had drug and alcohol workers working in mental health, which is something we don t have here. I mean, we re consulting into the facility. Ideally it would be good if we had a drug and alcohol worker who worked in mental health, who was there all the time, because we know that there are many people being admitted who are not getting the referral, which would be good. If we get the referral and we see their mental health, they re definitely referred to mental health, but it doesn t necessarily happen the other way around...(ef, 2009) In some senses then, EF is describing a partially working process by which people referred for drug and alcohol issues also get access to mental health help. The role of individual workers The role of the individual workers within services also played a large part in the narratives of both the workers and the clients when discussing organisational and structural difficulties. The focus of these narratives centred largely upon the understaffing of services, and excessive case loads individual workers bore. One drug and alcohol worker exclaimed,...it seem like mental health workers, case worker has been having too much, impossible workload, so much, that they were, I ve heard that one particular case worker had 40 cases (W: WP, 2009). In addition to excessive caseloads, other workers saw the complexity of each individual client with whom they worked as problematic for effective service delivery, particularly if there are issues around language as well: I think just the frustration people must feel is a problem working with these clients and sometimes they re hard work, they are more, if you re running a very busy service and someone who can t speak is just sometimes put in the too hard basket, not at this service particularly, but in places I ve worked. (W: EM, 2009) Possibly due to impossible workloads and the separation of drug and alcohol and mental health, when a client presents with multiple issues, one worker lamented: Unfortunately, I think they still get this, Not my job, sort of attitude from staff, and which is a shame because we ve had so many dual diagnoses projects over the years, and I still find it extremely annoying that people still fall through the cracks. (W: EF, 2009) This outcome is directly reflected in the narrative of MA, a current client of a large public outpatient drug and alcohol facility. MA says, If it gets too difficult, they just overlook it. I find that with a lot of agencies, they just overlook it once it becomes too difficult (MA, 2009). Difficulties we faced when negotiating the research governance processes of various drug and alcohol and mental health agencies are reflected in the comments of drug and alcohol worker EM, and in some ways, bear relevance to EF s comments regarding the geographical separation of drug and alcohol and mental health facilities. As EM says, I find there s a lot of empires around and people do very good jobs, but no one else really knows about it and I think it s the interface of the system that can be very difficult (W: EM, 2009). Two key reflections can be drawn from EM s comments. Firstly, that within services, there are individual workers that do help people with substance use and mental health issues. This is borne out in the narratives of some of the clients. In reflecting upon her time as a patient in a large public mental health inpatient facility, and the attitudes of the staff there, WW comments: There s no categorising. There s no favouritising here. It s just equal. They re very nice people. You know, they are. But mind you, I will not say at every other hospitals. I used Organisational and structural issues 100

101 to work at a psych unit myself, but as a nurse not as a patient, but, yeah I can t I truly can t fault this mental health. I could fault other ones that I ve worked in, but not this one. Yeah, definitely not. (WW, 2009) Similarly, drug and alcohol worker EM, has a favourable view of the individual workers within the system:..there s obviously a lot of well meaning individuals and/or that people who try very hard (W: EM, 2009). It seems, however, that despite the best intentions and skills of the workers, it is the system itself that may be inherently problematic, whether imperially, as EM describes, or because of geographical or modal separation, to which EF attests. System interface/access Secondly, EM refers to the interface with the system. For EM, the problematic nature of the system is partly constituted by attracting people to the service in the first place, and retaining the clients once there, especially if language and cultural differences exist: I think that knowing that the service exists is a major problem, like marketing the service for want of a better term and I guess marginalisation. People would often feel that the staff at a health centre does not understand their particular needs and I think find the interaction of language very difficult. I just think that they feel other to a point. (W: EM, 2009 [emphasis ours]) From this research, it is difficult to estimate how this sense of otherness, or the feeling of being generally alienated from society, is manifest for individuals before they access services for the first time, as we were only able to talk to people currently accessing services for mental health and/or drug and alcohol issues. This point poses an interesting starting place for further investigation, for example: questions could be asked of the individuals receiving service such as How approachable did you feel X service was in light of your cultural background? For those people from culturally and linguistically diverse backgrounds who were accessing services however, this otherness was manifest in several ways. Firstly, it was as if a process of reverse-inclusion sometimes operated. For example, WW, when asked if there were things at the large mental health inpatient facility that could be done to better accommodate their cultural background, replied: No. You know why? They can t just cater for everybody. It s just too hard. You know, there s a lot of people, and there s you know, like I m all right and I can speak and I can there are some people here that won t speak and that they need attention more than I do. (WW, 2009) Interestingly, contrasting with this statement, WW also tells how some of the patients do not eat while in the facility as the food there is not their customary diet, and how on occasion, she, WW, has acted as interpreter and intermediary for another patient who comes from the same linguistic background as WW themselves. For WW, therefore, otherness is a resignation to the systemic incapacity to accommodate people from all cultural and linguistic backgrounds. For some clients however, their otherness is characterised by being held in homogenous group, a group which in their view is heterogeneous and needs workers from corresponding CALD communities. For example, MA, in discussing their CALD background, says: They can t lump us all into the same category, they do need their own workers...that s very frustrating, they should have more Caseworkers, or Counsellors that are Maori, or... I think they have a program where they ve got Aboriginal Caseworkers and things like Organisational and structural issues 101

102 that, which is good. Cause I know other agencies don t have it; they don t have Aboriginal Caseworkers, or Maori, or Tongan or anything like that, and they need them. Same with Asian Caseworkers; they don t, I haven t seen any. (MA, 2009) For MA, then, their perceived otherness is a result if their interaction with individual workers, many of whom are presumably from non-cald backgrounds. By contrast however, in terms of system interface or access, many of the clients of the smaller services reported that they had found access a relatively simple process, and once within the service, found the service helpful. DD, for example, said, I made a call, and then about a month later I was in here speaking to somebody and I ve been coming back every week ever since, so I thought it was pretty easy, yeah (DD, 2009). In many of the clients narratives too, the service they currently attended was described as opening avenues to other services, providing linking-in possibilities. AJ, for example describes his experience with a mental health residential service: Yeah, this place has really, really helped me and like a lot of things have opened up since I ve been here. So it s pretty good, like work and study and TAFE, so it s pretty good, yeah (AJ, 2009). Resourcing issues sues The under-resourcing of drug and alcohol and mental health services does not go unnoticed by the clients of these services. In fact, it often formed the core of narratives in response to questions of how services could improve. MA, for example, is very clear in their observation of the staffing of the multiple services they have attended: A lot of them, because they are under-staffed, I can understand where they re coming from so I don t try and push them too much, which is wrong, because then I don t get the help I need (MA, 2009). There is fertile ground here for further investigation. Questions could be raised about the impact this observation by the clients has upon the efficacy of the treatment. As one client said, as you know that mental health system is like lacking in funds I guess so you can really tell when you re in there (NF, 2009). When questioned about the approaches that may work more effectively in helping them stay off the drugs, MA again reverts to the under-resourced nature of the service she is currently attending: Somebody that can come around, check on you, and make sure you re doing okay. Somebody you can call every day and they re not busy.i expected them to be doing that, and they re so under-staffed it s no point. (MA, 2009) Many frustrations are apparent in the narrative of MA in particular, often centred on the overburdening of staff and the desire to get help that is not forthcoming. She contextualises this within the context of literally being shoved to the back of the crowd, and there are not enough workers to get around to everyone, especially those at the back: They push you in the background cause you re so easy, and I ve found that all the way through. No matter what program I go to, if I m not loud, not push and force my way through things, I don t get any help, and I m not like that. So I sort of get left on my own... I just get frustrated that, they don t realise that the people that they should be helping are the ones that want help and just aren t being noticed. (MA, 2009) In some senses, MA s narrative is corroborated by EM, the drug and alcohol worker, but in a slightly different context. When asked about the different effects on service access and maintenance cultural and linguistic diversity might have, EM replied: Organisational and structural issues 102

103 .especially the Indo-Chinese people are very difficult to engage at a serious level. I find that by and large they re extremely polite and well mannered, and can slip under the radar easily as far as further engagement. They re very polite, but very private in their, and their linguistic skills obviously would prevent a lot of sort of banter that is often the introduction to further more sensible or deep interaction. (W: EM, 2009) Whether, therefore, it is the overloading of individual workers, the hesitance of the client in being demanding, or the reticence of the client, in many cases the system has not prevented clients from, as EF earlier described, falling through the cracks. Again however, in the clients narratives, it is often the valuable work of the individual workers that the clients found most helpful. Discussion At first glance, given the narratives of the clients and workers, it may seem that the system faces many challenges when helping people with co-existing drug and alcohol and mental health issues. Some of these challenges include separation of services, system access and resourcing. There is also however the encouraging aspect of the valued work of individual workers. In almost all of the client interviews the work of individual workers was at least recommended, if not extolled. Often this work was situated in the time and attention that individual workers gave the clients: The fact, I know it s just a good place. It s good surroundings, good people, they actually care more about stuff, like other than what s going into their wallets at the end of the week. If you re having a bad day, if you re having a hard time, they ll sit down and have a talk with you. (KC, 2009) Clients, in particular, reported that a service in which they were treated as individuals and that had a consistent and structured programme, were most helpful. What became clear, too, in the responses of the clients was how heavily a sense of self-identity rested with the role of the individual workers. For example, when asked for a recommendation on how best to work with them, OS replied, I think basically to treat everyone as an individual and everyone s situation individually. It s not a category of [pause] psycho, schizo, junkie [long pause] this person s made up of 100 different things (OS, 2009). Individuality and sense of self, and a sense that the workers were also committed to that sense of self largely formed the foundation for how the clients saw services should work. This is evident in the frustration and, to a degree, pathos of MA s narrative. When asked about difficulties she had faced with services, the following was foremost: Changing staff continuously. You ll get used to a Caseworker or a counsellor and then they change the staff. Then you get a new one, you get used to them, and then they change the staff. That s disappointing, cause I know a few people that are trying to help themselves but can t do it. It s a lifestyle thing, and then when you ve got to start all over again, you get over it. You don t want to keep doing it. What s the point? (MA, 2009) In another part of the interview, MA described how she felt that they did not have highly-developed communication skills, or many friends. When she exasperatedly ask, What s the point?, it is possible that MA is referring to much more than simply abstinence from drugs. The starting all over again could potentially refer to the constant imperative to build new relationships in what she perceives as an extremely transitory environment. For MA, so much of the socialisation processes in which she was engaged centres upon the contact with the workers at the drug and alcohol service she attends. Organisational and structural issues 103

104 As such then, while the system itself is seen by many, including clients and workers, as struggling to meet need, it is, at least in part, the interpersonal processes that take place between clients and individual workers that have a beneficial outcome on the clients substance and mental health issues. That staff attributes and organisational arrangements have a huge effect on treatment outcomes for clients is hardly surprising, and well borne out in the literature (Fixsen, Naoom, Blasé, Friedman & Wallace, 2005; Greenhalgh, Robert, MacFarlane, Bate, & Kryriakidou, 2004; Simpson, 2002; Simpson & Flynn, 2007a). What is interesting in this study however, and worthy of further investigation, is how significant the interpersonal relationships are between drug and alcohol and mental health workers and their clients. Organisational and structural issues 104

105 Implications of accommodating CALD There are many potential factors contributing to the implications of accommodating cultural and linguistic diversity in drug and alcohol and mental health service provision. Among these, the use of interpreters, materials in languages other than English, cultural competency and general knowledge of services available feature prominently. The vernacular, too, among the drug and alcohol and mental health services sector is often filled with discussion around how stretched current resources are. These discussions certainly made their way into the narratives of the workers in this study. Workers cited time poverty in particular as a concern in their jobs. Whether the case is that health services spending is in fact decreasing relative to the raw number of people accessing services is a frequently contested issue. In a qualitative study in 1996, the overriding government policy change identified by all respondents was the introduction of output based funding in the community health sector (Stanton, 2001: 673). This finding accords with a study in the United States that illustrated practitioners concerns about the deleterious effect reporting of outputs was having on the actual provision of service. 5 In some ways, this process can be related to the general approach taken in Australia over recent years. As Stanton notes: Australian governments have been increasingly influenced by neo-liberal approaches to policy making. [Neoliberalism is often referred to in Australia as economic rationalism (Stanton, 2001: 672)].This includes an increasing reliance on the use of market forces in the allocation of resources, utilisation of corporate sector management models and a decreasing role for government with a consequent cutback in government spending (Gardner, 1997, p. 3)(2001: 672). How has this economic rationalism affected the perception of workers in the fields of drug and alcohol and mental health services provision regarding the accommodation of cultural and linguistic diversity within their services? In this study, we sought to examine the implications of such an accommodation within these health services, especially in the context of the perception of already stretched resources. We also sought to examine the perceptions of the material costs of providing a genuinely culturallysensitive service and what are the impediments. Method In order to elicit from the workers the perceived implications of accommodating cultural and linguistic diversity in health services we asked the following: Currently, how many clients from culturally diverse backgrounds are you working with? What cultural backgrounds are they from? How did those clients come to be at your service? [referral pathway] Can you briefly describe their history with health services? Are there any common experiences your culturally diverse clients have had with health services? In your experiences what have been the difficulties in working with clients from culturally diverse backgrounds? Prompts sufficient bilingual materials, working with interpreters 5 See Kirschner and Lachicotte, Implications of accommodating CALD 105

106 (access, training, professionalism of interpreters), worker s cultural knowledge and attitudes, gender, family attitudes and perception of treatment We also aimed to examine the lived the experience of the clients of services in relation to their perception of the accommodation of their cultural and linguistic diversity within health services. For this reason, we asked: Can you think of any other problems you experienced that related to your cultural background? Such as: Being able to get the treatment of your choice/most appropriate treatment? Communication? [IF no or for further prompting] Was there anything about being from [your cultural] background that made treatment harder? Did you have any trouble getting into a service due to your cultural background? How do you think the service/s you went to could have been more understanding of your cultural background or your culture s way of doing things? By asking these questions we sought to go beyond an examination of access to services when multiple issues are present in order to highlight the perceptions of both the workers and the clients of the effects cultural and linguistic diversity might bring to service provision. Results Language and literacy Many of the perceived implications of both workers and clients of mental health and drug and alcohol services regarding accommodating cultural and linguistic diversity centred on language issues. Workers from a multi-culturally specific unit within an area health service note that not only are there few multilingual resources, but that these resources may not actually be as helpful as possible, citing expense as a contributing factor: There s a lot of emphasis, like everything is there and all the resources are available for English speaking but when it comes to non-english speaking the services become really diluted. Like the translations might not be as comprehensive, there might be a shorter version. So there s that cutting corners. Because it s expensive, it s an expensive exercise and who ends up getting, I was going to swear, who ends up getting these disadvantages, the clients. (W:CA & W:BP, 2009) 6 CA and BP issue a warning too, not to make assumptions about individuals and their preferred language of communication. CA and BP state that just because the client may speak English, does not necessarily mean that they do not self-identify as having a CALD background, nor that English is their preferred language of communication: 6 CA and BP were interviewed together. In the transcription process, their narratives were separated but not identified individually. Implications of accommodating CALD 106

107 Because there s such a myth about people who don t speak English are from CALD backgrounds but those who speak English are not. So they make that assumption. They might look at country of birth but not languages spoken at home. (W:CA & W:BP, 2009) Another worker who works in a community nursing practitioner role, highlights the complexity of language relations in CALD communities. According to KC, it is not always reasonable to assume that, even if a person has been living in Australia for many years, they have English proficiency, or that English is their preferred language of communication: There s a lot of older women who don t speak English who have lived here since they were 20 years old and coming up 60, have never spoken English, live at home, look after the men in the family; cook, clean, look after them. (W: KC, 2009) The perceived implications are therefore in many ways related to the capacity for organisations and individuals to provide service to people whose preferred language is other than English. CA and BP exasperatedly and resignedly state: Like a support group but those mainstreams don t cater for that. They look at people who speak English but they won t facilitate anything like that for people from non-english speaking backgrounds because it s too hard. It s too hard and when things are too hard... (W:CA & W:BP, 2009) CA and BP do not finish this sentence, but implied is that when things are too hard, they are simply too hard. Alternatively, CA and BP could be echoing mainstream cynicism about organisational capacity to accommodate languages other than English. Either way, CA and BP were not alone in their assessment of the capacity for organisations to accommodate cultural and linguistic diversity. Another worker also expresses this opinion, but with a slightly different focus: they have been working on a project through a community centre providing support to the primary carers of people with mental health issues: And I recently started to run one for the multicultural communities because there is a lot of minority ethnic groups that miss out because there s not enough numbers for the government to actually have a group in their own language, but their English is enough to communicate because we take a lot of care in how we communicate. That means we make it happen. That means it s not going to be the same as in their own language but still they gain something, being around people that have the same needs. (W:FT, 2009) Implicit within FT s narrative is the possibility that any communication around mental health issues is better than none that indeed, the too hard part relates only to the fact there are insufficient numbers among certain language groups to make, at present, these language-group sessions viable. In FT s narrative, some communication, despite language challenges is possible, as long as care is taken in the communication. How to actually promote this communication is for FT a large issue. As FT notes: I think that the information is there, but as it is very hard to attract the English speaking community that has a little bit more of an open mind about mental illness. It is hard to attract them. That means it s now going to be extremely hard to attract other people, to attract all the other communities. (W:FT, 2009) This analysis of the perceived implications of accommodating cultural and linguistic diversity was highly prevalent in the narratives of the workers. While formulated in several different ways, the theme remained the same: whether due to language or other reasons, it is very difficult to engage many people from CALD backgrounds with drug and alcohol and mental health services. Among the Implications of accommodating CALD 107

108 reasons given by workers, unfamiliarity with an English-language-based healthcare system was key. Worker AT, for example, traces this unfamiliarity to the very architecture of the system in New South Wales, and in particular generational differences within migrant families: I suppose just that understanding of the health system, I think, and I suppose they deal with those inter-generational problems with what's normal. The parents have grown up in a different country totally, where those services probably don't exist to the same degree, and there's a disparity between the generations. (W:AT, 2009) Another worker describes the difficulty in engaging people from CALD backgrounds as a product of little knowledge in the community about entitlements, echoing AT s comment regarding the services available in the migrants countries of origin: Cause they don t know where to go. I mean they might have been here for 20 years, they might have been here for three but you know they, they might not and they might have no conception that they would be entitled to some of the things that they might be entitled to. (W:DV, 2009) DV goes on to say that even if an individual from a CALD background had found a service, they may not necessarily have the knowledge around alternatives if they find themselves dissatisfied with that service: So an Aussie would, would think well yeah, I ll go somewhere else. If you re from somewhere where you can t do that, you [pause] So you know an Aussie would just think, yeah you can go somewhere else if you don t like it, but another person might not. (DV, 2009) Further, other workers attribute the disengagement of many people from CALD backgrounds from health services to the nature of service provision and models upon which service delivery is built: I think it s a lack of technical understanding of how things specifically work, in regards to, of course, obtaining the information in the first place...but I think it s also a premise on understanding some of the fundamental concepts in health practices that might not be understood completely. (W:KR, 2009) KR goes on to connect language, the family and unfamiliarity with the system when discussing the perceived implications of accommodating cultural and linguistic diversity within service provision: So for CALD, it s more around the parents not understanding the information contained in pamphlets and how that might be of use to themselves and to the family. But also what we find is that with both CALD and non-cald there might be some significant numeracy and literacy issues of being able to actually discern English written in those pamphlets. So that s even within non-cald, because of the lack of maybe education that those parents have. So both CALD and non-cald.and their ability to, again, understand the concepts contained in that particular information..so there s some of the difficulties I think that we find again regarding yeah, contact with health services. (W:KR, 2009) Interestingly, KR was unique in identifying multilateral literacy and numeracy issues as responsible for disengagement of all clients regardless of cultural background. Essentially, for KR, embedding service provision within culturally-appropriate messages was the best way to confront these issues:.we ve found that, even though they are being treated by the area health service, these families and individuals are still very much confused about what they have and what it Implications of accommodating CALD 108

109 means for themselves and their families. So for us we ve had to step in and provide more, I suppose, culturally appropriate approaches to the information that they needed and how that is then actually, I suppose, absorbed by those particular families. (W:KR, 2009) Working with interpreters Several key themes emerged when workers were asked about their experiences of working with interpreters in both drug and alcohol and mental health services settings. One of the most prominent of these themes centred upon the availability of interpreter services at the time at which they were really needed. AT for example, a worker in mental health services setting, describes this in the following way: You may have to book an interpreter a few weeks ahead and stuff, so you can t get it immediately, whereas it d be better to act immediately (W:AT, 2009). AT goes on to describe that which usually happens at the critical moment a face-to-face interpreter is required: [It] Can be a bit difficult to book them, or book them exactly when you need them for face-to-face, but in sort of more urgent situations, it is telephone interpreters (W:AT, 2009). Another worker, a community nurse practitioner, described the challenges they faced with the telephone interpreter service when managing crisis situations: Once you ve made the booking, that s okay. But if you re on the spot and you need someone there and then, and I know that I can access an interpreter through the telephone but when I m dealing with someone s sexual delusions (W:KC, 2009) Many of the workers commended the work of interpreters when they had been present during a consultation. The professional approach of interpreters was discussed in high regard by some of the workers, even in the context of challenges in accessing the interpreters services. BT, a worker in a mental health services setting, said: The interpreters now over the last 5 years have been really highly professional and I can only think of positives. They re very respectful in terms of interpreting exactly what you re wanting them to interpret. They have all the right protocols, in terms of looking at the right people and speaking in that way, they re highly skilled. I have absolutely nothing negative to say. It s always a positive experience when you re working with an interpreter and the only issue is, getting one fast. You always have to wait a week, 2 weeks. (W:BT, 2009) Other benefits of interpreter services were described not only in terms of language services. Some of the workers described the additional cultural sensitivity that interpreters brought to a consultation. This was particularly connected to situations in which the client themselves may have an understanding of the consultation as it occurs in English, but the family may have further challenges in gaining this understanding without the use of an interpreter. Worker AT for example, said: Probably a lot of the clients we have, the young ones possibly born here or something, their English is fine, but it s particularly for the families that even if they have sort of reasonable English, you find that once you get into more exploring sort of information, you sort of hit a brick wall if you don't use an interpreter. And I suppose it s not just about language, but it's just about some of the cultural meanings; what we mean and what they mean. (W:AT, 2009) Implications of accommodating CALD 109

110 Other workers described situations in which the interpreter was more adept at imparting complex information, often loaded with terminology that could seem quite obscure, rendering the clients understanding of the consultation superficial : Usually just a bit of information and explanation around a medical terminology, yeah, and so usually what we do is, defer ourselves to the idea that we have so much to say that we would like to get the message across and we may not have the right words for you to understand, so we need the interpreter more than you do. (W:BT, 2009) This worker contextualised the benefits of interpreted consultations within a situation in which the client may actually have some English and may then be considered by their family for the role of interpreter in the service setting: Mostly to all occasions where interpreters have been needed for clients, it s been fairly positive. Sometimes you get a bit of resistance when a client believes themselves completely capable of understanding but you know that there s only a superficial understanding and they re really not getting it, then there s a bit of resistance. That s not often, but sometimes when it comes to family members there s a bit more resistance, family members would prefer to bring their own family members for interpreting or prefer their son or daughter with the mental illness to interpret, so mostly always positive and uncomplaining at the introduction of an interpreter. Sometimes there s resistance, which is usually always over come fairly easily anyway. (W:BT, 2009) Worker BT s comments are echoed in the comments of YL, who works in a drug and alcohol service. In YL s experience, resistance to interpreted consultation may stem from the clients perception of their own English skills in the context of receiving complex information: I think some people who s English is fairly good often don t want to have an interpreter there for whatever reason, that they would prefer to see themselves as competent or whatever the reason is. So sometimes it s difficult negotiating that when it s someone who s, who does have a reasonable command of the English language. But when the concepts are quite complicated then it s a hard thing to get across. (W:YL, 2009) Potentially the source of greatest resistance from clients in using interpreters is connected to concerns around privacy and confidentiality. One worker in mental health service setting narrated a situation in which an interpreter was sought and obtained for a language group that at present does not have a large representation in New South Wales: A [particular language group] client that I have and the family had no knowledge of what was happening and very distressed and wanted help and pleading with me to help their daughter. And I could see the need; I needed to explain to them what was happening. So I thought the most common sense thing to do is to organise an interpreter and that caused so many problems because I think the sister of my client was, Oh no, no I will interpret you know we don t want him to do that, and I was trying to explain how that wasn t appropriate. And then they said, she said that the reason is that, We might know them we re a close knit community we might know them and so what we ended up doing was booking I think, I can t remember now but we booked one and it turned out that they did know her so all that happened and they agreed to everything, got to the hospital and saw her there and panicked and just left. (W:TM, 2009) This situation was reflected in the narratives of many of the other workers. EF for example, a worker in a drug and alcohol service setting, describes the privacy and confidentiality issue in the context of multi-lingual drug and alcohol and mental health workers: Implications of accommodating CALD 110

111 It s hard to find counsellors full stop really, but specifically I would like to refer people to someone that they will feel comfortable speaking with. I mean other than, sometimes people don t want to go and see somebody from their background because it might be a small community, and they don t want people to know. (W:EF, 2009) Another worker from a community-based service described a similar occurrence at the service at which they worked: [A service] that might not be suitable for them in some other way, for the client, it might you know location or the setting or they might know the person or something. And then sometimes they don t want to be, to talk to someone in their community about their problems, you know and what s going on. (W:DV, 2009) Effectively then, much of the resistance offered by clients to using interpreters stems from a concern that, especially if the client comes from a less-represented language or cultural group, there is the possibility that their substance use or mental health issues will in some way be made known to their communities through the interpreter. Two workers at a multicultural health service however suggested that this is extremely unlikely to occur: I ve never heard any, I mean it could happen but I have never heard anything leak out of any professional interpreters in the community, not even to us [laugh]. They wouldn t even tell us anything and we work in the same field. (W:CA & W:BP, 2009) Some of the workers described other challenges in working with interpreters, especially if the worker was able to provide services in the preferred language, other than English, of the client. Worker DV for example, who provides services in a language other than English, described interpreter-mediated consultations in the following way when compared with consultations that take place in their language other than English: I have done that before [use an interpreter] and it tends to be not so much counselling, just a kind of a support thing cause isn t good enough for the proper counselling. I tend to think that you can t really do counselling with a[n] [interpreter]. (W:DV, 2009) Worker DV narrated this in the context of their role as a generalist counsellor at a community health service. DV s response was the only one of its kind, yet draws a focus upon the mediating effect an interpreter may unintentionally or intentionally have in a consultation. One worker from a mental health service expressed concerns about the precision and accuracy of the information interpreted as a well as the effect itself of having an interpreter in the consultation: Sometimes I found interpreters may not be actually like you don t know if they re saying exactly what the client has said, so you are sort of still a bit hesitant whether they ve said that, but then some interpreters are really on the ball and they get it right, but yeah, sometimes you can t, you don t know if they are saying what the client says. Or sometimes they actually are speaking without the client, like even though they re sitting beside them, they sort of acting on their behalf without them, like they re not facing them and they re not actually talking to them, they re talking directly to the worker, which obviously makes the client feel a bit out of place. ( W:MN, 2009) Largely however, workers in drug and alcohol and mental health services described positive experiences when working with interpreters, once the interpreters were available. Workers spoke of the enhanced understandings achieved for both the clients and the workers as a result of using interpreters. AT describes their desire to use interpreters in the following way: Implications of accommodating CALD 111

112 I'm very happy to have an interpreter because otherwise you can go get quite incorrect information, I think, and you need to explore particularly the pre-morbid history. So to get into that sort of area, I think you need to be able to have time and interpreters to do that well. (W:AT, 2009) Stigma, shame, visibility and confidentiality So far, the interaction of language, the family and the nature of the healthcare system have been presented as the key sites where challenges are perceived to arise when accommodating cultural and linguistic diversity in mental health and drug and alcohol services. That stigma and shame is commonly felt by people experiencing drug and alcohol and mental health is widely reported in the literature. 7 One worker, in talking about the position of someone with substance use and/or mental health issues, connects directly the shame with lack of knowledge of services available: Stigma, just lack of what is happening to them, avoidance maybe, I mean I often think that if I was in that situation it would be so hard it would be like, it would be so easy just to avoid out of shame and like not knowing where to go, what to say. (W:TM, 2009) For another worker however, when discussing these issues to include people from CALD backgrounds, there is a tension between the person with substance use and/or mental health issues disclosing with their family, and keeping the issues hidden:.the cultural stuff, depending on the culture and, like if you re looking at a Muslim culture, where to admit that you ve got a drug and alcohol problem, ostracises you from your religion and your community and everything. So you ve got to look at you know, what happens in the sense of culture, that if I acknowledge it, I ve got a problem, do I need to keep it secret. If I kept it secret from the family and my community to go and get help? So there s that bit of it, like the conflict between the family and the cultural belief about drug or substance use, and the confidentiality that goes around that. And then the conflict of confidentiality versus family support (W:KC, 2009) Recognising this tension is pivotal in successfully accommodating cultural and linguistic diversity in service provision for many people. Workers also expressed concerns about the perceived visibility of someone from a relatively small community when accessing a service: That s because especially if it s a small community, I think, they want to ensure their privacy someone from whatever background sees that there's not many people from that background going to a service, then they ll be a bit more hesitant, I think. (W:AT, 2009) AT is here talking about the visibility (rather than confidentiality) of a client from smaller community attending a service. Visibility and confidentiality are here two distinct concepts. The service, and workers, for example, can undertake to ensure absolute confidentiality is maintained this does not mean however that visibility is averted. Another worker from a hospital-based outreach mental health team reflected upon the accommodating the privacy and confidentiality needs of some of their CALD clients in the following way: 7 See Corrigan et al., 2006 for a systematic review of the literature. Implications of accommodating CALD 112

113 confidentiality in terms of other people in the culture finding out or other people in the street finding out I ve had a couple of clients you know, asked me to not use my not put my ID on or to park down the street so that the health car isn t seen and... so again stigma because we do a lot of work outside the hospital and in homes and I m quite conscious sometimes if... sometimes I will take off my ID, especially in public, because I might meet a client in a shopping centre or out in public and I try and remember to take it off cause I feel uncomfortable for them. (W:TM, 2009) Confidentiality therefore became an important interest when perceptions of accommodating CALD were discussed. Food and special treatment The nexus between the narratives of the workers and the clients regarding perceived implications of accommodating cultural and linguistic diversity occurred at several locations. At one of these, interestingly, food becomes symbolic of this accommodation process particularly in the narratives of the clients who self-identified as coming from a CALD background. One client, a patient at a large public residential mental health facility, had suggested that it was not possible for the institution as it were to accommodate every culture and all linguistic diversity. In the same interview, this client, WW, narrated this vignette: Look, I m sorry, but they re not eating and I worry. You know, I worry. And the lady said to me, I know. I know. I said, Listen. I said to the mother this is the mother of the child, I m Greek and my mother bring me Greek food. Why can t you make Lebanese food and bring it in? You know, they ll eat it. They ll go in their room and they ll eat it. They don t have to eat it in front of us. But, you know, they re not eating nothing. You know, it worries you. [From the context of the interview, it is apparent that the preceding five sentences are self-talk as opposed to dialogue that WW may have had the mother of the Lebanese client.] That s an example. (WW, 2009) For WW, food became a symbol both of the inability of the system to cope effectively with cultural diversity, and the role of their family in their treatment. For a worker who had, some years previous, initiated a move that endorsed families bringing food into the institution, the issue of food also had symbolic significance: Okay this guy wants to eat rice, we can do it but then we created a whole big problem in [service name] where the Anglo says How come he s being treated special from us, how come he can t eat the food we eat and how come he s allowed to have visitations and we are not allowed to. (W:KW, 2009) KW s narrative regarding perceived inequities is echoed in the narratives of some the clients when they discuss service provision more generally. For example, MA, who attends a large public drug and alcohol health service, sees that a certain cultural group receives much more attention than others, but that this too occurs in the context of that which could be viewed as a limitation of the organisation the competencies of the staff: They get more. They get a lot more They get a whole lot; they get away with a lot. They re rude, they stamp their feet and they get what they want, and if you re not as loud as them and you re not as pushy as them, you don t get as much help All they do is raise their voice and they seem to get what they want. They intimidate people and a lot of the Nurses and that aren t very street-wise, so they get intimidated really easy. (MA, 2009) Implications of accommodating CALD 113

114 In sum, CA and BP perhaps provide the tersest account of the perceived implications of accommodating cultural and linguistic diversity in drug and alcohol and mental health service provision. They describe it as a trifecta of disadvantage: So I guess it s something, CALD backgrounds just not on the agenda for a lot of people because like I said, time, money and it s too hard and I couldn t be bothered, yeah so unfortunately (W:CA & W:BP, 2009). CA and BP were here speaking as if from the perspective of workers who did not see the possibility of accommodating CALD in service provision. They themselves did not however hold this view. Insufficient resources, including time, money and staff competencies therefore render the perception of accommodating cultural and linguistic diversity as too hard. Discussion In the responses of the clients and workers emerge several key themes in the implications of accommodating cultural and linguistic diversity in drug and alcohol and mental health service provision. Materials in languages other than English and interpreting services were narrated as key sites where challenges arise, the literacy of clients with regard to the issues they faced also providing challenges. Stigma and shame around drug and alcohol and mental health issues more generally also became apparent, with specific issues around confidentiality prominent when discussing the challenges faced by people from CALD backgrounds. Special treatment, bending the rules around food for example, was also seen as an implication of accommodating cultural and linguistic diversity. There is a tension between the account of CA and BP and, in many cases, that which was observed in this study. For example, many services do indeed have materials in languages other than English, are aware of the interpreter services available to them and have provided training in cultural competency. What are some of the possible ways to account for this tension? Some of the workers hinted at the possibility that while there is a veneer of inclusion, multilingual resources for example, there remains an underlying premise of exclusion. KC, for example, describes this as racism: I know that we ve got all these services and non-english speaking background, multicultural and people like you and that s all well and good; but on the floor when it comes to the coal face, if I know that I ve got to legging to stand on to say to you, That is racism, it s not tolerated then I can change the culture of how we look after people and how we treat people. You know what I mean, it s well and good for me to have a set of standards but if it can t be enforced across the board, it doesn t work. So while culture and mental illness and substance abuse are the issues that you re looking at, racism is what will really affect the outcome of that. And if there s legislation that prevents racism then all those other issues from my point of view can be worked out properly. (W: KC, 2009) In New South Wales, legislation and policy exist to prohibit discrimination on the basis of race and to promote inclusion in health services. 8 In some senses however, in the practice of drug and alcohol and mental health service delivery, it is possible to identify a cultural lag, as suggested by Kirschner and Lachicotte (2001: 442). Cultural lag refers to the process by which practitioners at the front line are able to circumvent unwieldy processes prescribed by legislation or policy in order to provide 8 New South Wales Anti-Discrimination Act 1977 and Enshrining the principles of cultural diversity in legislation and Charter of Principles for a Culturally Diverse Society Handbook, New South Wales Department of Health,1997, for example. Implications of accommodating CALD 114

115 beneficial outcomes for their clients. In their study of a community mental health facility in a city in a north-eastern state of the United States, Kirschner and Lachicotte (2001) found a process by which practitioners were able to bend the rules to continue to provide service to their clients. This found form in extending the period of service beyond that for which the client was funded through novel accountancy practices and other similarly subversive actions. These acts Kirschner and Lachicotte (2001) describe as resistance. In the present study, this cultural lag was in some ways characterised by practitioners willingness to work outside the boundaries usually prescribed by the organisation for which they worked. One worker, KW, described the rather unorthodox, bending of the rules that he undertook: I impressed the families so much, I ve really poured in my heart and soul to work with this kid, that I got invited to their place because it was the mother s birthday. To the house in [suburb of Sydney] where they make this traditional Vietnamese banquet and we just sit around and after that the father came and sat and had a beer and started talking about his progress with his son because of what I said to him and stuff like that. (W: KW, 2009) The results from this study suggest that there are complex interactions between the individual workers and the system in which they work, particularly as these relate to accommodating cultural and linguistic diversity. For example, there is policy to promote inclusion and equity across health services in terms of practice there are service level practices (such as those in relation to food) where workers and clients became agents overcoming perceived deficits of the system. The same is true of the worker, FT, who started a multicultural group, overcoming the systematic deficit and logistical difficult of accommodating everyone s preferred language. Alternatively, there are attitudes and practices presented where individuals and services can subvert perceived benefits in the system, such as the opinions expressed by workers CA and BP s last quote in the results. And then there is the greyer matter in between where the individual can choose to be a facilitator (or not) of the benefits of the system as discussed in the early part of the results, centreing on understanding the system. In this case it is not necessarily a deficit of the system itself, but how it is being enacted by individuals. Then there are workers such as AT, DV and KR who are concerned about facilitating informed navigation of the system, whereas others may not recognise or choose to engage with that aspect of service. In many ways therefore, individual workers can overcome the perceived deficits of the system in accommodating cultural and linguistic diversity by offering resistance to the confines of the system. Implications of accommodating CALD 115

116 Recommendations and conclusion Implications of accommodating CALD 116

117 Recommendations The primary aim of this project was to investigate the experiences of clients, particularly those from a CALD background, in accessing appropriate and specialist care for co-existing cannabis use and mental health issues. In so doing, an intended outcome of this project was to develop recommendations focussed on improving access and quality of care for people from a CALD background who have co-existing cannabis use and mental health issues. This section outlines the recommendations that have emerged from the narratives of both the client and worker participants in this study. Method In order to make recommendations that were grounded in the experiences of clients and workers within drug and alcohol and mental health services a range of questions were asked of all participants. These are presented below: Questions to clients How do you think services can better help people from non-english speaking backgrounds? How do you think services can better help people who experience both drug dependency issues and a mental illness? What advice would you give a worker who was working with someone from [your background] for the first time? What advice would you give a worker who was working with someone who had both drug and alcohol issues and mental health issues? Questions to workers How do you think services can better help people from culturally diverse backgrounds? How do you think services can better help people who experience both drug dependency issues and a mental illness? What advice would you give other [workers insert job role] who are working with clients from culturally diverse backgrounds for the first time? [Prompt for different backgrounds] What advice would you give other workers who are working with clients who have both mental health and drug dependency issues for the first time? The following additional question was asked of CALD clients: What do you think workers need to know when they are working with people from [your cultural] background? The following additional questions were asked of workers: What can services do to increase service access for people from culturally diverse backgrounds who have comorbid AOD and mental health issues? Do you know of any initiatives that have worked well? Recommendations 117

118 What can services do to improve treatment outcomes for people from a culturally diverse background who have comorbid AOD and mental health issues? Do you know of any initiatives that have worked well? Responses to these questions form the basis of the recommendations presented on working with clients who have co-existing mental health and drug use issues, and working with clients from CALD backgrounds. The recommendations have been categorised according to whether they were targeted at the worker or service level. Working with clients who have co-exi existing issues The following recommendations were made in relation to working with clients who have co-existing drug use and mental health issues. Understand where people are coming from and how they see their drug use and mental health Specifically, this included the following recommendations made by clients: Be aware of people s problems and knowledge before giving advice. Listen and try to understand where people are coming from, what they have experienced and how they have been brought up. Understand clients individual experiences and understandings of how their mental health and drug use intersect, or whether they see themselves as having co-existing issues: Understand psychological problems and don t lump us all together. All the agencies lump us as all in the same category, and we re not. The help I need is not the same as the people with psychological problems. (MA, 2009) Additional recommendations made by workers were: Listen to clients past experiences and coping mechanisms rather than, after making a diagnosis, just telling people what they have to do. Understand where people are at and how you can help them navigate, rather than expecting them to start from your perspective or understanding. Treat people with respect and care Specifically, this included the following recommendations made by clients: Have a non-judgemental attitude: Basically don t judge, that s one thing you do not do to someone do not judge them by just looking at them (KW, 2009). Treat people in a manner that acknowledges their age and experience. Have your heart in it: You ve kind of really got to like your job to, especially in this business. If you don t like your job, you re not really helping anybody [worker s name] you can tell he s got the heart in it (ND, 2009). Demonstrate your commitment by coming across like you care (BM, 2009). Recommendations 118

119 Build relationships and trust for when people are ready to seek help Specifically, the following recommendation was made by client KW: If they don t open up to you at first, give them time And basically once you ve built that trust you can almost help them anyway you can if they re not ready to do anything, it s only a matter of time until they come to the self-realisation that they do need help or they do need someone to talk to it s just building up trust that s all it comes down to is trust and if a worker, if a client doesn t trust a worker, there s no point, you know what I mean? (KW, 2009) Additional recommendations made by workers were: If people are reluctant to talk about drug use or mental health issues, offer another type of service or context of relating as an entry point, through which people might begin to address issues. Engage with people through other service types who may have clients with coexisting issues, such as emergency food relief or homelessness services. Structure services to reflect the occurrence of coexisting drug use and mental health issues Specifically, this included the following recommendations made by clients: Provide assistance for mental health in drug and alcohol services, and vice versa. Continue to modify how services operate to reflect an understanding of the link between drug use and mental health. Additional recommendations made by workers were: Increase the level of understanding and education on co-existing issues. Provide appropriate services for people with co-existing issues so they are not in that twilight zone of service delivery (W:EM, 2009). Provide services for specific needs Specifically, this included the following recommendations made by clients: Provide intensive case support as found in youth services for those aged over 20. Provide for age specific needs, so people from similar stages of life are together: They d understand the struggles and they could have different kinds of workers address that Sometimes it s difficult cause people don t understand where you re coming from (TM, 2009). Improve services for people with less visible symptoms Specifically, this included the following recommendations made by clients: Provide adequate support services for those with less severe mental health symptoms living independently: If you show them that you can do things on your own, and you re pretty together, they don t bother to help you So a lot of people like me, they just slip through the gaps, Recommendations 119

120 cracks, do you know what I mean?...they re just put into the main population and pushed through, and they wonder why they relapse. (MA, 2009) Additionally, one worker recommended the following: Target resources and approaches within services to improve service quality for those who are less visible: just like the troublesome child at school, there s the one who s throwing chairs at the teacher, you ll get noticed, it s the quiet ones probably won t get noticed (W:LS, 2009). Help to prevent relapse through fostering support networks Specifically, this included the following recommendations made by clients: Organise regular reunions (e.g. BBQs) for former clients of residential rehabilitation programs, and support linkages to other supports, so they can continue relationships and build on support networks: because the thing when you stop doing something you end up alone and that s one reason why you tend to go back to it (SJ, 2009). Additional recommendations made by workers were: Create mentoring programs and support networks between former clients, this will also help build the self-esteem of the mentor and further empower former clients. Address people s needs and situations in a holistic way Specifically, this included the following recommendations made by clients: Provide services that address the entirety of people s needs, involving other services where required. One client spoke of an inpatient service she found particularly helpful: they can actually bring in the whole community, the outer community, like Legal Aid, social worker, other needs, like accommodation and help you they ll guide you within [the services] for when you get out. (WW, 2009) People may need additional assistance to what is provided in a given service: especially for people from backgrounds who ve come physical and sexual abuse, particularly females that I ve met, they probably could have done with a little bit more than the rehab could offer (EW, 2009). Additional recommendations made by workers were: Where possible, provide continuing care (previously called aftercare ) by linking those who have exited programs with workers with whom they have had ongoing contact. Link community-based clients with opportunities for work and study. Provide more resources so there is time for workers to address needs more holistically and engage more intensively with clients: More resources in terms of two things, people power. So we have lesser case loads and we can intensively engage people and keep them engaged and secondly in terms of getting them functional in work and study.i ve noticed from personal experience for someone who s had a psychosis and possible cognitive impairment if see people twice a week, which I do, some, there s a greater improvement, but I can t see everybody twice a week. (W:BT, 2009) Recommendations 120

121 Promote services and improve i knowledge of where to go for help and support Specifically, this included the following recommendations made by clients: Increase knowledge of what services exist and who can help since you don t know these things unless you contact one [service] and then you get referred onto the other and then the other, and it s like it s never ending Cause it s like, when you re in that state especially with mental health, you re more lost than anything (EP, 2009). Have one website that lists all the services so people could go to that website and find out which services they really need, cause at the moment they re all kind of scattered (LH, 2009). Run mass media campaigns (TV, radio, cinema advertising) with messages informing people about: Psychosis can occur due to drug use, and that there are places you can go to get help. Co-existing drug use and mental health issues, in order to let people know where services are, how to access them, and help them feel more comfortable about seeking help rather than hide it. Additional recommendations made by workers were: Engage in prevention and early intervention by connecting with other service types, such as schools, to promote your service and provide information on indicators of mental health or drug use issues. Continue training t and education Specifically, this included the following recommendations made by workers: Provide ongoing education for workers. Maintain an appropriate standard level of qualifications and training for those working with people who have mental health and drug use issues. Increase the evidence base Specifically, this included the following recommendation made by a client: Provide a lot more research in terms of long term links between different drugs and different mental health issues and the reverse as well, the links between mental health issues and the drugs that people would choose to use (QM, 2009). Recommendations 121

122 Working with clients from a CALD background The following recommendations were made in relation to working with clients who are from CALD backgrounds. Make interpreter services readily available to clients Specifically, this included the following recommendations made by clients: Clients should have the right to ask for either an interpreter or someone that has a more comprehensive understanding of their background or culture. It should also be offered to them by workers because if you re sitting in there feeling like crap you may not know what you re entitled to (UM, 2009). Have capacity for ready availability of interpreters since if something significant happens or something is going down sometimes, no matter what you say in English or Australian, it s better in your own language said (WW, 2009). Additional recommendations made by workers were: Ask people if they understand what you are saying in English, and if not use an interpreter. Understand where people are coming from and find out about their culture Specifically, this included the following recommendations made by clients: Find out about someone s culture, ask questions: if you get a new client and you re not aware of their culture look into it, get educated and be respectful. It s okay to ask questions if you re unsure; just do it in a polite way (TO, 2009). Try to be educated and aware of different cultures, beliefs and practices and make room for them to be able to practice what s in their culture and stuff, especially in residential rehabs (TO, 2009). Try to understand where people are coming from, be open minded, not judgmental or critical of other people s backgrounds. Additional recommendations made by workers were: Find out if there are any services or workers from the same cultural background as a client with whom you can liaise in order to: get advice or find out more about the culture, or to link a client up with them. Operate on a case by case basis rather than making assumptions on what people would want based on their culture background. For example, some people prefer gender specific counselling whereas others do not, and for some family or community involvement is crucial, whereas for others not. Find out more about the culture your clients are from, you can also speak with the interpreter afterwards and enquire about the culture and any beliefs or attitudes from that culture related to drug and alcohol or mental health issues. Recommendations 122

123 Approach CALD as just another facet of someone s experience: It s just one more thing in dealing with that client, like their other issues. Like their homelessness, mental health, their employment status or their sexuality, it s just one more thing that needs to be addressed in the pot of the issues you re trying to deal with. (W:EM, 2009) Invest more time in explaining things and relationship building Specifically, this included the following recommendations made by workers: Take the time to build the relationship with a client. Explain more about the healthcare system, health and community services in Australia and what counselling is as they may not be familiar counselling or what is involved. Offer choices and explain why they are being offered so they are able to choose. Promote effective two-way communication where clients issues, perceptions and understandings are really communicated, so they do not become lost in the system, cause people will smile and they ll be polite, and then just go out and be lost through the cracks (W:EM, 2009). Provide holistic services, particularly addressing issues related to refugee or migrant experiences Recommendations made by workers were: Provide additional support for issues specific for newly arrived migrants and the migration experience, such as understanding how Centrelink operates or assistance with applications to the Department of Immigration. Network with other services, know about different services, make contacts and learn from how other services operate: I would be very interested to hear if there is another agency who works in a similar area and how they overcome some of the difficulties rather than having a presenter from somewhere that speaks about working with non-english speaking clients (UJ, 2009). Liaise with CALD communities Specifically, this included the following recommendations made by clients: Engage with community elders or leaders who can liaise between a service and the community. Additional recommendations made by workers were: Have a service open day so members from a particular community group can come in and have a look around, maybe with a local worker from their background that can support them to show them around, and explain what the service does, so they don t feel so intimidated (W:SR, 2009). Do more outreach, that is, go out to where clients are, since, for some, even though the service is not far geographically psychologically it s a really long way (W:DV, 2009). Recommendations 123

124 Continue to develop cultural competency and knowledge Specifically, this included the following recommendations made by workers: Increase cultural awareness and what that means in relation to providing assistance with drug and alcohol or mental health issues: I think that s one of the key things that we re dealing with here, is equity and access. And I think one of the ways that we can try and develop more of a response from both the community, but also from statutory service providers, is cultural awareness and appreciation, so development of cultural capacity and/or competency in being able to deal specifically with specific ethnic communities and their scope on mental health and alcohol and other drugs. So it s one thing to be culturally competent in a particular ethnic community, but it s another thing to contextualise that information in mental health and alcohol and other drug stuff and mental diagnosis stuff. (W:KR, 2009) Have resources, such as DVDs, on different cultures that are reliable and accessible for when the information is needed. Promote knowledge within services of cultures that are predominant in the local area. Have staff who are sources of knowledge for particular cultures, who then stay informed and inform other workers. Increase staff knowledge by having team meetings on different cultures or getting cultural leaders or representatives in to talk to staff about their culture and beliefs: once they ve got education around it and they ve got an understanding of it, the fear side of it is broken down... they re able to work with young people better (W:UW, 2009). Have a culturally diverse workforce with bilingual / bicultural workers Specifically, this included the following recommendations made by workers: Make services more accessible for people from CALD backgrounds by having a culturally diverse workforce. I think that ringing up and making appointments, not having very good English, being on drugs and having a mental illness, if you ve got someone that totally understands the language barrier and understands where you come from it may be a bit more appealing and a bit more open to access the service. (W:MN, 2009) Have bicultural workers who can understand the subtleties of the culture, how to communicate effectively and, if attitudes need challenging, how to do so in a polite and honourable way. Increase service engagement by reduc r educing language barriers Specifically, this included the following recommendations made by workers: Provide further training on the challenges faced for people from CALD backgrounds when contacting services. For example they have access to interpreters and things like that but it s not as easy as that they need to tell us if they need an interpreter. Every one of us knows how difficult it is to navigate through an automated phone system (W:TM, 2009). Increased resources to engage more effectively: More people power, if I could pick up a Vietnamese speaking interpreter twice a week and take them on a home visit and engage the whole family as well as the client, so everybody s supported, everybody knows and it s not just the client we re engaging with Recommendations 124

125 while the mother who speaks no English is hovering in the background not knowing who this stranger is and what she s talking about with her son or daughter in English. So, engagement is about the whole process, in terms of client and the family, just more people power again. (W:BT, 2009) Discussion Recommendations made by both clients and workers demonstrate the depth of knowledge and experience among the participant group and the value gained through providing a space for participants, particularly clients, to provide input into sector development and continuous quality improvement. Comments made by clients were either borne from their own experiences in accessing services, both positive and negative, or from the observed difficulties and challenges faced by other clients, particularly those due to language or cultural differences. Amongst the workers interviewed much was said regarding skills and approaches that are helpful when working with people from CALD backgrounds. Recommendations encompassed engaging interpreters or bilingual workers, operating on a case-by-case basis, learning more about clients cultures, providing holistic services, increasing service engagement, reducing language and cultural barriers and continuing to develop cultural competency. Despite this depth of knowledge there was no mention of acknowledging or understanding the impact of workers own values, assumptions, culture, religion, gender or age, when interacting with clients. While that is not to say that workers were not self-aware in this way in their approach to working with clients, it is of note that concepts around selfawareness and self-assessment were not clearly articulated when workers were asked to give advice to others in relation to either working with clients who have co-existing issues or working with clients from CALD backgrounds. Recommendations 125

126 Limitations The limitations of this study largely centre upon accessing participants for whom English is neither their first, nor preferred language. Much effort and strategy was employed to access this population. For example, an ethno-specific service was contacted, participant information and consent forms were prepared in the language this service most commonly uses, and interpreters and multilingual interviewers were at the ready to undertake interviews. Nonetheless, all of the interviews in this study were undertaken in English. This outcome may point to the relatively reduced numbers of clients in services for whom English is not their preferred language and that no participants were referred from ethno-specific services. Approximately half of the participants self identified as coming from a culturally and linguistically diverse background. It was estimated that 3 of the 52 clients who fitted the eligibility criteria may have preferred to speak a language other than English, or have an interview conducted in their first language. Given that the recruitment process was arm s length, these three clients were referred to the research team as English speakers and not preferring a language other than English. Upon first meeting, while the research team asked whether they would prefer the interview conducted in another language, these participants decided to go ahead with the interview in English. The specific limitation here therefore relates to gaining enhanced understandings of the barriers to healthcare experienced by people for whom English is not their preferred language. Further investigation could therefore be warranted in examining the specific experiences of barriers and pathways to healthcare among people for whom English is not their first or preferred language. Such an investigation may use a more focused selection criteria, recruiting for example participants who have either substance use or mental health issues, or by concentrating on recruiting from ethnospecific services. In this study, the clients of drug and alcohol and mental health services were not asked how approachable they felt services were. Had questions around the perceived approachability of services been asked, further understanding of the clients choices to use certain services may have been yielded, contributing to the knowledge base around pathways to service. Further investigation could therefore take up this theme in order to enhance understandings of pathways and barriers to healthcare for people with co-existing substance use and mental health issues. As the methodology of this study is primarily qualitative, the usual limitations to generalisability apply. The endeavour was however to explore the experiences of people from culturally and linguistically diverse (CALD) backgrounds who have co-existing substance use and mental health issues. This exploration is both thorough and detailed. At no point however, is it claimed that the experiences of the clients in this study represent the experiences of all CALD clients of drug and alcohol and mental health services, nor potential CALD clients, nor sub-groups of particular groups, such as the subgroups within Arabic-speaking populations. Given the heterogeneity inherent within the descriptor CALD, it is unlikely that any study would in fact be able to draw such conclusions. Further investigation though could be warranted into the experiences of people from specific language or cultural groups to further elucidate the experiences of those within these groups. A limitation of this study could potentially be seen in the recruitment of clients. While there was a diversity of drug and alcohol and mental health services, both government and non-government (NGO), from which clients were recruited, there was a noticeably larger proportion of clients recruited from NGO services. Although approval to conduct the research was sought at the area health service (AHS) level, the reason for the strong representation from the NGO sector was largely related to the complex and time-consuming research governance processes within AHSs. For non-government services the ethics approval from the NSW Population and Health Services Research Ethics Limitations 126

127 committee largely sufficed, with additional approval from agency management. In defence of this study, it can be argued that the clients spoke of their experiences with both government and NGO services, but further investigation may lead to examining the effects situation may have had on the narration of pathways and barriers to healthcare. So, for example, the narration of pathways and barriers may differ significantly for those who have only ever experienced NGO residential rehabilitation programmes when compared with someone who had only ever experienced a government-run opiate treatment programme. Further investigation may provide enhanced understandings of the effects of situation on the narration of pathways and barriers to treatment for coexisting substance use and mental health issues. Less of a limitation and more of an avenue for further investigation, in this study, it was the experiences of people who had been able to access drug and alcohol and mental health services that were examined. While in these narratives certain barriers to healthcare became apparent, nonetheless it was in the service setting that the clients were interviewed, suggesting, as aimed, more about pathways than barriers to healthcare. This research did not aim to examine these barriers. Despite the logistical and ethical challenges however, further investigation could potentially include the experiences of people with CALD backgrounds who had co-existing substance use and mental health issues who were not currently seeking treatment. Examining these experiences may further enhance understandings of barriers to healthcare for people who experience these issues. Limitations 127

128 Conclusion The overarching research question for this project is: What are the experiences and pathways to specialist mental health and alcohol and other drugs (AOD) treatment for culturally and linguistically diverse (CALD) clients with co-existing cannabis use and mental health issues? The answer to this question is as complex and multifaceted as cultural and linguistic diversity itself. In this research, the dominant constructions of mental illness in NSW were examined particularly in the context of the effects these constructions may have on CALD populations accessing help. The experiences of clients from a CALD background with co-existing cannabis use and mental health issues in accessing appropriate and specialist care were qualitatively examined along with the pathways to specialist mental health and/or AOD treatment for CALD clients with co-existing cannabis use and a range of mental health issues. The degree to which being from a CALD background influences the time and pathways taken to specialist care was examined as well as the levels of engagement by those from a CALD background with mental health and AOD treatment services. This was compared with the general community, and any impact this has on individuals and families dealing with co-existing issues was explored. Interviews with clients were used to map the pathways to AOD and mental health services, and the range of experiences of CALD clients in accessing appropriate and timely treatment for co-existing mental health and cannabis use issues was explored. Largely, the aim was to identify particular access and equity issues for CALD clients in accessing appropriate and timely treatment and to develop recommendations focused on improving access and quality of care for people from a CALD background who have co-existing mental health and cannabis use issues. In speaking with clients and workers in AOD and mental health services, key themes emerged from their experiences. There was heterogeneity in the ways the clients narrated co-existing substance use and mental health issues, with some clients attributing their mental health issues to cannabis use, while other spoke of their substance use in general, and cannabis use in particular, as helping to ameliorate depression. When clients spoke about their experiences with mental health and drug and alcohol services, they often engaged the language of therapy, and in particular the language surrounding cognitive behavioural therapy (CBT) and Alcoholics and Narcotics Anonymous (AA/NA). Workers suggested that for some culturally and linguistically diverse communities, the CBT and AA/NA models need to be augmented with approaches that take account of the individual cultural and family background from which the clients come, including for example, the spiritual aspects of the individual client s experiences with substance use and mental health issues. In the narratives too of both the clients and workers, many understandings of mental health and substance use issues were revealed. In some ways, these narratives point towards the social construction of these issues and the need for a flexible and individualised approach when engaging with the language and modes of therapy. The complex interaction of family and culture was described by many of the CALD selfidentifying clients, and a great diversity was apparent in these narratives. On the one hand, for example, some CALD clients viewed their families as great supports in their managing mental health and substance use issues, while others preferred to keep their families at a distance pending their own recovery. In almost all the clients narratives, a form of crisis had brought them both to services initially, and the service they were currently attending. The interconnectedness of all of the elements of these situations, including housing, family and sometimes contact with the criminal justice system, was described in the experiences of the clients and workers alike. In some ways too, this interconnectedness had had an effect on the ways in which the clients had experienced service access, particularly as the clients narrated their individual agency in getting help with their substance use and mental health issues. Cultural and linguistic diversity also appeared to have an influence on Conclusion 128

129 which services the clients in this study accessed, with substantially fewer attending residential rehabilitation services when compared with non-cald self-identifying clients. Many of the workers and clients identified issues around organisational structures and practices that both assisted and impeded clients in getting help for their substance use and mental health issues. The valuable input of individual workers was contrasted in these narratives with service separation and challenges in system access, particularly for CALD clients. In some ways too, the perception of accommodating cultural and linguistic diversity had an effect on how services were delivered. In the experiences of some participants, accommodation of diversity took place as a result of individuals subverting the system (or bending the rules), while in others experiences, diversity was accommodated by putting the system to work, in the case of using interpreters for example. Yet others saw the accommodation of cultural and linguistic diversity in an informed navigation of the system at large. The accommodation of cultural and linguistic diversity was, in the experiences of the clients, worked towards when practitioners had flexible and sensitive approaches. In combination with empathy, and the fostering of coping skills, many clients in this study reported feeling included. Conclusion 129

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148 Appendices Appendix 1a - Site Specific Assessment: A real world example 1. An SSA was submitted to the ethics office of a large hospital within an area health service, but before having gained the Chief Executive s signature as the researchers were unaware that this was the protocol. This was an oversight on the part of the researchers as this part of the SSA submission protocol is freely available at Authorisation of proposals to conduct research on humans within NSW public health system (NSW Health, 2007: 2.1.6). 2. The ethics officer very helpfully guided the researchers through any necessary inclusions for the attached documents, such as the participant information and consent forms, as well as pointed the researchers in the direction of the signatories required. 3. The SSA requested accessing the whole of the hospital campus as well as any attached mental health units. 4. The clinical director of the mental health stream of the area health service provided their consent, so the researchers thought they had permission to access that site for their project. 5. Later in the project, the researchers hoped to conduct a face-to-face interview with some of the clients of the drug health service located on the campus of the same hospital. The researchers were informed by the research co-ordinator within drug health services at this hospital that there were further processes, specific to that hospital, the researchers needed to undertake in order to gain access to that department. 6. The researchers referred back to the ethics officer, who clarified that it would indeed be necessary to specify on the SSA exactly the site for which the researchers wanted access, for example, drug health services, accident/emergency, the cardiac ward, paediatrics, and so forth. 7. In an attempt to expedite the SSA process, another SSA was sent to the director of drug and alcohol services for that AHS, in the hope that their signature would open the research pathway to all drug and alcohol services within that area health service, in much the same way as the signature of the director of mental health services in that AHS had opened the pathway to mental health services. 8. As at 6 th November 2009, seven months after submitting this SSA, we had no reply regarding this SSA. We did however receive approval from the director of the drug health service at that hospital to conduct research at that site alone. Appendices 148

149 Appendix 1b - Timeline for ethics approvals The timeline for approval, conditional on the piloting of questionnaires, for the project to commence, was: 1. Early March 2008: Submission of original NEAF to P&HSREC th March 2008: P&HSREC meeting th March 2008: Letter notifying of required amendments to project plan received. (While this letter requested a response within three months, a further month s extension was requested by DAMEC due to staffing issues.) th August 2009: P&HSREC meeting st September 2008: Letter notifying of further required amendments to project plan received st October 2008: Ethics approval provided conditional upon standard reporting requirements th December 2008: Request to amend Participants Information and Consent forms (PICF) and invitation to health professionals st January 2009: Request for amendment of 8 th December granted th March 2009: Request for amendment of advertising flyers th April: Request for amendment of 11 th March granted th May: Request to add two more AHSs to the study th May: Request of 4 th May granted th July 2009: Piloted questionnaires submitted for approval th August 2009: Piloted questionnaires approved. The timeline for accessing the AODTS NMDS in the Treatment Pathways for CALD clients with comorbid cannabis use disorders and mental illness research project was: 1. 3rd March 2009: Data sets requested from NSW Health th March 2009: Authority from Director NSW Health Mental Health and Drug and Alcohol Office received. 3. 7th April 2009: Data sets received (but not used pending approval from the P&HSREC HREC) nd April 2009: Request made to P&HSREC HREC to use data sets th May 2009: P&HSREC HREC meeting. 6. 1st June 2009: Approval from P&HSREC received data sets may now be used. Appendices 149

150 Appendix 2 - Participant information and consent form TREATMENT PATHWAYS FOR F CULTURALLY AND LINGUISTICALLY DIVERSE (CALD) CLIENTS WITH COMORBID CANNABIS USE DISORDERS AND MENTAL ILLNESS Dear Participant, The Drug and Alcohol Multicultural Education Centre is investigating the experiences of culturally and linguistically diverse clients in accessing drug treatment and mental health services. The purpose of this research is to identify how access and quality of care can be improved for people from a CALD background who have a mental illness and cannabis use disorder. The responses you provide will help us do this. Agreeing to be interviewed will mean that you will be asked questions about your experiences in accessing treatment for a mental illness and cannabis use disorder. The questions will focus on the process of referral, the kinds of treatment and services you have accessed and received, your experiences during treatment and contact with health workers. You are not obliged to answer any question you do not want to or feel uncomfortable with, and you are free to stop the interview at any time. With your permission your responses will be audio recorded. Responses will be kept confidential and anonymous at DAMEC premises under lock and key. The only person who will see your responses will be the person who transcribes the interview and the researcher. The responses you give will be combined with other people s responses to anyone being identified. When the project is finished I will send you a copy of the final report either by post or and then dispose of your contact details. This study has been approved by the NSW Population and Health Service Research Ethics Committee. Any person with concerns or complaints about the conduct of this study should contact the Executive Officer on (02) and quote protocol number 2008/03/067. Kind Regards, Ian Flaherty, Comorbidity Research Officer, DAMEC - Information letter for clients, V Aug DAMEC Appendices 150

151 TREATMENT PATHWAYS FOR F CULTURALLY AND LINGUISTICALLY DIVERSE (CALD) CLIENTS WITH COMORBID CANNABIS USE DISORDERS AND MENTAL ILLNESS Dear Participant, The Drug and Alcohol Multicultural Education Centre is investigating the experiences of culturally and linguistically diverse clients in accessing drug treatment and mental health services. The purpose of this research is to identify how access and quality of care can be improved for people from a CALD background who have a mental illness and cannabis use disorder. The responses you provide will help us do this. Agreeing to be interviewed will mean that you will be asked questions about your experiences in working with clients from a CALD background who have been diagnosed with a comorbid cannabis use disorders and mental illness. The questions will focus on the process of referral for such clients, the kinds of treatment and services available, and your experiences in working with CALD clients and families. You are not obliged to answer any question you do not want to or feel uncomfortable with, and you are free to stop the interview at any time. With your permission your responses will be audio recorded. Responses will be kept confidential and anonymous at DAMEC premises under lock and key. The only person who will see your responses will be the person who transcribes the interview and the researcher. The responses you give will be combined with other people s responses to anyone being identified. When the project is finished I will send you a copy of the final report either by post or and then dispose of your contact details. This study has been approved by the NSW Population and Health Service Research Ethics Committee. Any person with concerns or complaints about the conduct of this study should contact the Executive Officer on (02) and quote protocol number 2008/03/067. Kind Regards, Ian Flaherty, Comorbidity Research Officer, DAMEC - Information letter for health professionals, V.1.1 Aug 2008 DAMEC Appendices 151

152 CONSENT FORM I.agree to participate in the following research project: Treatment pathways for CALD clients with comorbid cannabis use disorders and mental illness Name of Researcher/Interviewer: The researcher has discussed this research with me, I have had the opportunity to ask questions about the research and have received satisfactory answers. I have read and kept a copy of the attached information sheet and understand that I can withdraw from the research at any time. I agree that the information collected for the study can be published, or provided to other researchers at DAMEC, as long as it does not identify me in any way. Signed by participant: Date:. Signed by researcher..date:. This study has been approved by the NSW Population and Health Service Research Ethics Committee. Any person with concerns or complaints about the conduct of this study should contact the Executive Officer on (02) and quote protocol number 2008/03/ Consent Form, V.1.1 Aug DAMEC Appendices 152

153 Appendix 3a - Advisory group terms of reference The Drug and Alcohol Multicultural Education Centre (DAMEC) warmly invites you to participate in an ADVISORY GROUP (Research) [AGR]. DAMEC is a non-government organisation which seeks to bridge the gap between alcohol and other drug services and culturally and linguistically diverse communities. DAMEC has recently been funded by NSW Health to conduct a qualitative study on the experiences of people from CALD communities in accessing services when presenting with co-morbid cannabis use disorders and mental health issues. The AGR will inform the development of this new research project, and provide editorial support for the duration of the project. The representatives will provide input into developing culturally sensitive research protocols and advise on social, cultural and clinical contexts for service-seeking behaviour among the target group. The representatives may also be asked to recommend key informants to interview. Meetings will be conducted when key milestones have been achieved. A schedule of the key milestones will be made available to all representatives. On this basis, we anticipate that the time commitment of membership would be approximately six meetings for the 18-month course of the project, as well as unscheduled and informal contact with the researcher. An agenda for each meeting will be made available for all participants at least two weeks before each meeting. Project details This project will investigate the experiences of people from a culturally and linguistically diverse background (CALD) who experience both cannabis use and mental health issues. The research aims to look at the avenues people from a CALD background use to access mental health and/or drug services. The degree to which being from a CALD background influences access to specialist care, appropriate treatment, and experiences in treatment will be examined. The research methodology will be primarily qualitative, involving in-depth interviews with clients of mental health or drug treatment services who have been diagnosed as having both a cannabis use and mental health issues. Health professionals will also be interviewed about their experiences in treating CALD clients with co-existing issues, as well as their perspectives on access and equity issues related to CALD clients receiving appropriate treatment and diagnosis. The project has ethics approval from the NSW Population and Health Services Research Ethics Committee, Cancer Institute NSW. Terms of reference The following comprise the Terms of Reference for this Advisory Group (Research). While it is anticipated that the emergent material will be of interest to all representatives, it is understood that, due to the varied academic and experiential backgrounds of the representatives, some terms of reference may apply more closely to some of the representatives than others: 1. To advise on designing research in a sensitive framework; 2. To advise on sensitive issues around the discussion of cannabis use and mental health issues; 3. To provide insight into the experiences of people from CALD backgrounds who have coexisting cannabis use and mental health issues; Appendices 153

154 4. To provide insight into the experiences of specialist service providers when treating the target population; 5. Within an editorial framework, advise on methods for overcoming the underutilisation of services by the target group; 6. Within an editorial framework, contribute to the literature around co-existing cannabis use and mental health issues among CALD communities. As a member of the AGR, your contribution will be recognised in official reporting on the project. You will also be invited to launches and related project functions. Please feel free to contact the Researcher, Ian Flaherty on Alternately, you can Ian at [email protected]. You can find out more about DAMEC and our activities on Appendix 3b - Advisory group members The following were members of the project advisory group: Anthony Arcuri (NCPIC) John Howard (NCPIC) Peter Gates (NCPIC) Connie Donato-Hunt (DAMEC) Ian Flaherty (DAMEC) Tina Smith (MHCC) Tricia O Riordan (NSW Health Department: Mental Health & Drug and Alcohol Office) Ranjini Ganendren (NSW Health Department: Mental Health & Drug and Alcohol Office) Robert Stirling (NADA) Peter Todaro (MHCS) Appendices 154

155 Appendix 4a - Questions for clients 1. What is your cultural background? 2. What health services have you been to in the past? 3. [Ask questions 4 to 6 for each treatment service listed in question 2] 4. Can you remember when you were a client of X service? [Further probes: How old were you when you first went there? How long ago were you there?] 5. What were you there for? What were you receiving treatment for? 6. What were the main reasons you went to service X? 7. What did you want to get out of your time there? 8. Who referred you? Who brought you there? [self referral, doctor, nurse, health care workers, a drug and alcohol counselor, telephone helpline services, staff at a detox facility, staff at a pharmacy] 9. I have list of different types of services. I m going to go through them and ask you to tell me if you ve ever had experience with them and what it was. [Read through the card with AOD & mental health treatment options - page 3] 10. What things have been challenging for you since you ve been getting help for your mental illness / drug and alcohol issues? 11. Have you had any problems or difficulties at the services you ve been to? 12. What difficulties have you had getting what you wanted out of being at a service? 13. [If yes] What kinds of problems? 14. Do you think any of these problems were related to you being from [your cultural] background? 15. Can you think of any other problems you experienced that related to your cultural background? Such as: Being able to get the treatment of your choice/most appropriate treatment? Communication? 16. [IF no or for further prompting] Was there anything about being from [your cultural] background that made treatment harder? 17. What is the attitude towards mental health and drug and alcohol issues in [your culture]? 18. Did you have any trouble getting into a service due to your cultural background? 19. [Ask if in a mental health service] Have you had any issues with drugs or alcohol? 20. [Ask if in a D&A service] Have you had any issues with mental health? 21. Did you have any trouble getting into a service due to having drug use problems as well as a mental illness? 22. Was there anything about being from [your cultural] background that made treatment easier? [If yes, prompt for what kinds of benefit/s.] Appendices 155

156 23. Was there anything that services you have been to did that you found particularly helpful? [If yes, what were they? ie. access to an interpreter, understanding of cultural background, involved family members, same culture clients in the services, varied culture clients in the services.] 24. How do you think the service/s you went to could have been more understanding of your cultural background or your culture s way of doing things? 25. Do you think people from a non-english speaking background get the same access to services or help as other clients? 26. Do you think people with drug dependency issues and mental illness get the same access to services or help as people who only experience one or the other? 27. Of the services you have been to, which ones were good at working with people from different cultural backgrounds? [what is it about the service that makes them good at working with people from different cultural background/s?] 28. Of the services you have been to, which ones were good at working with people with both drug dependency issues and mental illness? [what is it about the service that makes them good at working with people?] 29. What do you think workers need to know when they are working with people from [your cultural] background? 30. How do you think services can better help people from non-english speaking backgrounds? 31. How do you think services can better help people who experience both drug dependency issues and a mental illness? 32. What advice would you give a worker who was working with someone from [your background] for the first time? 33. What advice would you give a worker who was working with someone who had both drug and alcohol issues and mental health issues? 34. Ask for postal details, in order to be able to forward a copy of report to participant. Types of services: Community health service Mental health residential unit Detox Residential, outpatient or home detox Community Based Treatment Residential rehabilitation Methadone, Buprenorphine or Naltrexone Drug counseling GP - for medication Psychiatrist Psychologist Self help groups Self-managed change Peer support Any others? Appendices 156

157 Appendix 4b - Questions for health professionals 1. During your working life in what job roles have you worked with clients from culturally diverse backgrounds? What cultural backgrounds have they been from? 2. Currently, how many clients from culturally diverse backgrounds are you working with? What cultural backgrounds are they from? 3. How did those clients come to be at your service? [referral pathway] 4. Can you briefly describe their history with health services? 5. Are there any common experiences your culturally diverse clients have had with health services? 6. What problems might clients from culturally diverse backgrounds experience when accessing health services? 7. In your experiences what have been the difficulties in working with clients from culturally diverse backgrounds? Prompts sufficient bilingual materials, working with interpreters (access, training, professionalism of interpreters), worker s cultural knowledge and attitudes, gender, family attitudes and perception of treatment 8. What problems might clients with comorbid cannabis use disorder and mental illness experience when accessing health services? 9. In your experiences what have been the difficulties in working with clients who have a comorbid AOD and mental health condition, particularly in relation to cannabis use? 10. In your experience, what have been the strengths of working with a client with a comorbid condition? What has made it easier for you? What has made it easier for the client in treatment? 11. What can services do to increase service access for people from culturally diverse backgrounds who have comorbid AOD and mental health issues? Do you know of any initiatives that have worked well? 12. What can services do to improve treatment outcomes for people from a culturally diverse background who have comorbid AOD and mental health issues? Do you know of any initiatives that have worked well? 13. What do you think your service does well in their work with clients from culturally diverse backgrounds? How do you think your service can improve in treating culturally diverse clients? 14. Do you think people from a culturally diverse background have the same access to services as other clients? How about clients who do not speak English well or at all? 15. Do you think people with drug dependency issues and mental illness get the same level of treatment as people who only experience one or the other? 16. What advice would you give other [workers insert job role] who are working with clients from culturally diverse backgrounds for the first time? [Prompt for different backgrounds] Appendices 157

158 17. What advice would you give other workers who are working with clients who have both mental health and drug dependency issues for the first time? 18. How do you think services can better help people from culturally diverse backgrounds? 19. How do you think services can better help people who experience both drug dependency issues and a mental illness? Appendices 158

159 Appendix 5a - Advertisement for worker participation Working with culturally and linguistically diverse clients who have drug and alcohol and mental health issues The Drug and Alcohol Multicultural Education Centre (DAMEC) is investigating the experiences of people working with culturally and linguistically diverse clients who have co-existing issues. As part of the project we are looking to interview workers who have clients: With co-existing cannabis use and mental health issues; From a culturally and linguistically diverse background; And are currently in treatment. Each interview would be a maximum of 45 minutes. DAMEC recognises your expertise and would greatly appreciate your assistance. If you would like to take part in this valuable research project, or for further information on the project, please contact Ian Flaherty on: , , or [email protected] It would be greatly appreciated if you could forward this information to your networks. Appendix 5b - Advertisement for client participation Are you from a non-english speaking background? Have you had issues with cannabis and mental health? If you answered yes to either or both of these questions then your health worker might tell you about a study interviewing people about their experiences with health services. The study is being conducted by an organisation called DAMEC. Ask your health worker for more details. This research is being conducted by the Drug and Alcohol Multicultural Education Centre (DAMEC). To contact phone or [email protected] Appendices 159

160 Appendix 6 - Vietnamese translation of the participant information and consent form NHỮNG PHƯƠNG HƯỚNG TRỊ LIỆU CHO THÂN CHỦ GỐC VĂN HÓA VÀ NGÔN NGỮ KHÁC BIỆT (CALD) BỊ CÙNG LÚC CẢ CHỨNG RỐI LOẠN DO SỬ DỤNG CẦN SA LẪN BỆNH TÂM THẦN Kính thưa Người Tham Gia, Trung Tâm Giáo Dục ða Văn Hóa Về Ma Túy và Rượu ñang ñiều nghiên về những kinh nghiệm mà các thân chủ gốc văn hóa và ngôn ngữ khác biệt ñã trải qua khi sử dụng các dịch vụ cai ma túy và chữa trị bệnh tâm thần. Mục ñích của cuộc nghiên cứu này là ñể xác ñịnh cách thức cải thiện việc sử dụng và chất lượng chăm sóc cho người gốc CALD bị mắc bệnh tâm thần và chứng rối loạn do sử dụng cần sa. Những câu trả lời của quý vị sẽ giúp chúng tôi ñạt ñược mục ñích này. Khi ñồng ý cho phỏng vấn có nghĩa là quý vị ñồng ý cho chúng tôi hỏi quý vị về những kinh nghiệm ñối với việc ñược chữa trị bệnh tâm thần và chứng rối loạn do sử dụng cần sa. Những câu hỏi này sẽ chú trọng ñến quá trình giới thiệu, những phương pháp ñiều trị và các dịch vụ quý vị ñã tìm ñến và sử dụng, những kinh nghiệm của quý vị trong lúc chữa trị và việc tiếp xúc của quý vị với nhân viên y tế. Quý vị không bắt buộc phải trả lời bất cứ câu hỏi nào trái ý muốn của mình hoặc quý vị không cảm thấy thoải mái và có toàn quyền ngưng cuộc phỏng vấn bất cứ lúc nào. Nếu quý vị cho phép, cuộc phỏng vấn sẽ ñược thâu âm. Các câu trả lời sẽ ñược lưu giữ kín ñáo và ẩn danh trong tủ khóa kỹ tại cơ sở của DAMEC. Những người duy nhất sẽ xem những câu trả lời của quý vị là người ghi chép lại cuộc phỏng vấn và người nghiên cứu. Các câu trả lời của quý vị sẽ ñược kết hợp với các câu trả lời của người khác ñể không có ai bị lộ danh tánh. Khi ñề án kết thúc, tôi sẽ gởi cho quý vị bản báo cáo chính thức qua ñường bưu ñiện hay và sau ñó sẽ xóa bỏ chi tiết liên lạc của quý vị. Cuộc nghiên cứu này ñã ñược Ban ðạo ðức Nghiên Cứu Dịch Vụ Y Tế và Dân Số NSW (NSW Population and Health Service Research Ethics Committee) chấp thuận. Bất cứ người nào có ñiều gì quan tâm hay khiếu nại về cách thức thực hiện cuộc nghiên cứu này, xin liên lạc với Nhân Viên ðiều Hành (Executive Officer) qua số (02) và ñọc số 2008/03/067. Việc thực hiện cuộc nghiên cứu này ñã ñược Dịch Vụ Y Tế Khu Vực South Eastern Sydney Illawarra cho phép. Bất cứ người nào có ñiều gì quan tâm hay khiếu nại về cách thức thực hiện cuộc nghiên cứu này cũng có thể liên lạc với Nhân Viên Quản Trị Nghiên Cứu (Research Governance Officer) qua số và ñọc số 2008/03/067. Ian Flaherty, Nhân Viên Nghiên Cứu Trường Hợp Bị Hai Bệnh Cùng Lúc (Comorbidity Research Officer), DAMEC - Information letter for clients, V Aug DAMEC Appendices 160

161 Giấy Ưng Thuận Tôi.ñồng ý tham gia ñề án nghiên cứu sau ñây: Những phương hướng trị liệu cho thân chủ CALD bị cùng lúc cả chứng rối loạn do sử dụng cần sa lẫn bệnh tâm thần. Tên Nhân Viên Nghiên Cứu/Nhân Viên Phỏng Vấn: Nhân viên nghiên cứu ñã thảo luận với tôi về cuộc nghiên cứu này, tôi ñã có cơ hội ñể ñặt câu hỏi về cuộc nghiên cứu và ñã ñược giải ñáp thỏa ñáng. Tôi ñã ñọc và lưu giữ một tờ thông tin ñính kèm và hiểu rằng tôi có thể rút ra khỏi cuộc nghiên cứu này bất cứ lúc nào. Tôi ñồng ý cho thông tin thu thập cho cuộc nghiên cứu này ñược công bố hay cung cấp cho những nhân viên nghiên cứu khác tại DAMEC miễn là nó không làm lộ danh tánh của tôi. Chữ ký của người tham gia: Ngày:. Chữ ký của nhân viên nghiên cứu..ngày:. Cuộc nghiên cứu này ñã ñược Ban ðạo ðức Nghiên Cứu Dịch Vụ Y Tế và Dân Số NSW (NSW Population and Health Service Research Ethics Committee) chấp thuận. Bất cứ người nào có ñiều gì quan tâm hay khiếu nại về cách thức thực hiện cuộc nghiên cứu này, xin liên lạc với Nhân Viên ðiều Hành (Executive Officer) qua số (02) và ñọc số 2008/03/067. Việc thực hiện cuộc nghiên cứu này ñã ñược Dịch Vụ Y Tế Khu Vực South Eastern Sydney Illawarra cho phép. Bất cứ người nào có ñiều gì quan tâm hay khiếu nại về cách thức thực hiện cuộc nghiên cứu này cũng có thể liên lạc với Nhân Viên Quản Trị Nghiên Cứu (Research Governance Officer) qua số và ñọc số 2008/03/ Consent Form, V.1.1 Aug DAMEC Appendices 161

162 Appendix 7 - Client service use history Client How Service Fragmented or Cultural Motivating factor / long Total First service First service referral Current service Current service referral types continuous service background Why ago services accessed history yrs 1 Anglo-Australian AOD resi rehab AOD issues Criminal justice system c.3 AOD inpatient Criminal justice system AOD Fragmented 3 2 Anglo-Australian GP Co-existing issues 2 AOD inpatient Outpatient service AOD Both frag. and contin. 3 3 Anglo-Australian Community health AOD issues Self 12 AOD inpatient Self AOD Fragmented 4 4 CALD AOD resi rehab AOD issues Self 0.2 AOD inpatient NA (1st service) AOD 1st service 1 5 CALD Hospital Mental health issues Family 16 MH inpatient Self MH Only service 1 6 CALD Psychiatrist Co-existing issues DoCS 0.2 MH inpatient Outpatient service MH Continuous 3 7 CALD Hospital Co-existing issues Criminal justice system 0.2 MH inpatient NA (1st service) AOD and MH 1st service 2 8 CALD Psychiatrist Mental health issues Family >5 MH inpatient Self MH Both frag. and contin. >7 9 CALD Hospital Co-existing issues Family 3 MH inpatient Inpatient service MH Continuous 4 10 CALD GP Mental health issues Self c.6 MH inpatient Inpatient service MH Fragmented 3 12 CALD Hospital Mental health issues Family 1 MH inpatient Inpatient service MH 1 period 2 13 Anglo-Australian GP AOD issues Self c.1 AOD inpatient Self AOD Continuous 3 14 Anglo-Australian Counsellor Mental health issues >10 AOD inpatient Self AOD and MH Continuous 3 15 Anglo-Australian Hospital Mental health issues Criminal justice system 4 AOD inpatient Self AOD and MH Fragmented >5 16 Anglo-Australian AOD resi rehab AOD issues Self 24 AOD inpatient Self AOD and MH Fragmented >10 17 CALD GP Co-existing issues Self 2 MH outpatient Self MH Both frag. and contin CALD Psychologist Mental health issues Self 0.2 AOD inpatient Family AOD and MH Fragmented 2 19 Anglo-Australian GP Mental health issues c.10 AOD inpatient Criminal justice system AOD 1 period 2 20 Anglo-Australian Hospital Mental health issues Self >8 MH outpatient Self MH Continuous 3

163 Client How Service Fragmented or Cultural Motivating factor / long Total First service First service referral Current service Current service referral types continuous service background Why ago services accessed history yrs 21 Anglo-Australian AOD resi rehab AOD issues DoCS 0.2 AOD inpatient NA (1st service) AOD 1st service 2 22 CALD Hospital Co-existing issues 6 MH inpatient Inpatient service MH Both frag. and contin Anglo-Australian Counsellor Mental health issues Other 7 MH inpatient Outpatient service MH Continuous 3 24 CALD Hospital Mental health issues Family MH inpatient Inpatient service MH Fragmented 4 25 Anglo-Australian Counsellor Mental health issues Other >3 AOD inpatient Self AOD and MH Both frag. and contin Anglo-Australian Hospital Co-existing issues Other 1 AOD inpatient Outpatient service AOD and MH Continuous >5 27 CALD Detox AOD issues Self 20 AOD outpatient Outpatient service AOD and MH Fragmented >10 28 Anglo-Australian AOD counselling AOD issues Family 0.6 AOD inpatient Family AOD and MH Fragmented 3 29 CALD Psychologist Co-existing issues 9 AOD inpatient Criminal justice system AOD and MH Fragmented >8 30 Anglo-Australian GP AOD issues Self 15 AOD inpatient Inpatient service AOD and MH Both frag. and contin. >10 31 CALD Hospital Mental health issues Family 4 AOD inpatient Self AOD and MH Both frag. and contin. >10 34 Anglo-Australian Community service Other Other 2 AOD inpatient Outpatient service AOD Continuous 4 35 Anglo-Australian AOD resi rehab AOD issues Self 6 AOD inpatient Outpatient service AOD and MH Continuous 4 36 Anglo-Australian Detox AOD issues Self c.8 AOD inpatient AOD and MH Fragmented >6 37 Anglo-Australian Detox DoCS involvement Self c.0.7 AOD inpatient Self AOD 1 period 2 38 Anglo-Australian Counsellor Mental health issues Family c.4 AOD inpatient Criminal justice system AOD and MH Both frag. and contin. >6 39 CALD Community health Co-existing issues Other 6 AOD outpatient AOD and MH Fragmented >6 40 CALD AOD resi rehab DoCS involvement Self 1 AOD outpatient Self AOD 1 period 2 41 CALD Psychologist DoCS involvement DoCS 2 AOD outpatient Self AOD Fragmented 2 42 Anglo-Australian Detox AOD issues 17 AOD outpatient Self AOD Both frag. and contin Anglo-Australian GP Mental health issues Self 20 AOD outpatient Self AOD and MH Fragmented 4 Appendices 163

164 Client How Service Fragmented or Cultural Motivating factor / long Total First service First service referral Current service Current service referral types continuous service background Why ago services accessed history yrs 45 CALD Hospital Mental health issues Other AOD outpatient Criminal justice system AOD and MH Fragmented 3 46 CALD Psychiatrist Mental health issues Family >3 AOD outpatient Self AOD and MH Fragmented CALD GP Mental health issues Criminal justice system AOD outpatient Criminal justice system AOD and MH Fragmented 7 48 CALD GP Mental health issues 10 AOD outpatient AOD and MH Both frag. and contin Anglo-Australian Psychiatrist Mental health issues DoCS 18 AOD inpatient Self AOD and MH Both frag. and contin. >6 50 CALD AOD outpatient AOD issues Self c.5 AOD outpatient Self AOD Only service 1 51 CALD AOD outpatient AOD outpatient AOD Only service 1 52 CALD Psychologist AOD issues Criminal justice system AOD outpatient Criminal justice system AOD 1 period 2 53 CALD AOD outpatient Mental health issues Self AOD outpatient AOD and MH Continuous 3 54 Anglo-Australian Community service Other Criminal justice system 1 AOD inpatient Criminal justice system AOD Continuous 5 55 Anglo-Australian AOD community Co-existing issues Family 12 AOD inpatient Criminal justice system AOD Both frag. and contin Anglo-Australian GP Mental health issues Self >1 AOD inpatient Outpatient service AOD and MH Both frag. and contin. >9 Appendices 164