AICAFMHA:
promoting mental health for young Australians
Australian Infant, Child, Adolescent and Family Mental Health Association Ltd
ABN 87 093 479 022

Does this remote community really need a Child and Adolescent Mental Health Service or could it even do damage?
Brendan Sheahan, Area Coordinator, Child & Adolescent Mental Health Service, Far West Area Health Service, Broken Hill, New South Wales

Introduction
Community needs
Planning
Key people to involve
Implications

Introduction

Recruitment difficulties and technological advancements are factors that greatly impact on remote community mental health service delivery. This paper looks anecdotally at the issues of introducing new services and concepts into remote communities that have evolved and maintained their own social fabric and structures. It poses the question of how have small communities coped and how they may react to changes to their structure and functioning, particularly in matters relating to family.

This title is not a challenge to the child psychiatry establishment but rather the question I pose to myself in my role as a service planner. It is a particularly relevant question to anyone developing or delivering services in remote communities. It is about sustainability, fragility and how did the community cope before services arrived with interventions and what we can learn from that.

Essentially this paper is about my anxiety in planning the development and delivery of Child and Adolescent Mental Health Services (CAMHS) in remote communities that have not previously had access to such services. The anxiety is two fold. Firstly I have never worked in an environment where the intended effects of a program have been potentially so publicly scrutinized and the outcomes of the interventions so clearly distinguishable. Secondly with the new political focus on the "bush" and technological advances such as video conferencing there is a wave of "metros dropping in or beaming in" to provide advice or services. Unfortunately at times they may be transposing what has worked or is currently trialing in their metropolitan settings with little regard or understanding of the local dynamics.

The Far West Area Health Service was set up primarily to service all the remote communities in NSW rather than a number of Area Health Services having a few in their patch. By grouping them it was envisaged that expertise and focus on remote communities would be an outcome. Most of our thirteen towns are less than one thousand five hundred in population. This raises a critical question of whether they have different social and community structures. Are there social forces in remote communities that don’t impact on service delivery planning in even larger rural settings? If there are, then how do we work with them to provide the best outcomes for consumers?

Approximately six years ago in a northern Victorian town, I initiated a meeting in a rural town with a population of 600 to discuss establishing a child and adolescent mental health service. It could be argued that this town was reasonably isolated from mainstream services across the board. I had gone to this town not because they had asked for services or that there was any particular child and family issues; but rather I had been told that all towns in the agency’s catchment area must be seen to be being serviced. Eight women attended the meeting. Four grandmothers and four mothers. Some of the participants had professional backgrounds. The outcome of the meeting was that they probably didn’t need child mental health services as they had trust in the strengths of their families and community. They thought it would be okay if CAMHS came every two months. Their major concern was some "single parent families" were moving in from elsewhere because the housing was cheap and they wanted to maintain the student numbers at the local school. The school principal, health services staff and the policeman generally agreed that probably the only significant issue for the children was underage binge drinking, but they were addressing this already. However whilst I was moving between meetings that day, two of the mothers from the meeting individually sought me out and privately expressed their wish that they be able to access child mental health services without their extended family’s knowledge. The reason given was they just didn’t want the town knowing their business. It was not that they didn’t have faith in their community’s ability to rally around if problems arose with children.
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I took this as justification to commence a service. That town since has received a very inconsistent service from a variety of clinicians and has reverted to an "as required" service. The service provider made this decision. I don’t know if they are better off but I am sure changes resulted because of our presence. At the time I really did not give due consideration to the expressed opinion of those mothers and grandmothers. I had a service provision box to tick and tick it I did. This town has since received an adhoc service from a variety of clinicians and has reverted to an "as needs" basis.

The town of Wee Waa in northern NSW has recently provided us with some insight into a community response to a dramatic event. Following a rape of an elderly local resident it was proposed that all male residents over the age of sixteen undergo voluntary DNA testing. This group numbered approximately 600. The impression I gained from media reports is that the vast majority of the target group participated. What motivated this group to participate? Was it community pressure, was it a heart felt gesture to the victim or did they want to make sure the offender was not still in their town? Regardless, it demonstrates that a sense of community exists and they were motivated into an action as a collective. This then begs the question; in what size population does this sense of community exist and when does it dissipate? Is it 1000, 2000, 5000 or above? In a small town, when are you able to be anonymous and not connected to those you pass in the street?

The rural town of Portland in Victoria inadvertently changed the statewide protocol for a community response to a critical incidence. There was a brutal double murder of two elderly local women and the offender was never apprehended. When local services requested assistance to what they perceived to be altered daily functioning in the community (door locking, mistrust and anxiety) they were informed that if this was to happen in a metropolitan setting then those directly involved would receive services and this would normally be limited to witnesses and neighbors. It was considered that people living a city block away would not suffer any reaction at all. However in Portland these murders were the first since bushranger times and it was realized some six months down the track that functioning of a broad number of community members had altered and a response was forth coming.

Returning to the communities of the Far West of NSW it is important to recognize why they may function differently and how these factors should influence the service delivery planning process.

The task I have is to establish a sustainable, appropriate and viable Child and Adolescent Mental Health Services in townships that have no previous CAMHS experience therefore no real expectations and potentially some resistance to the services introduction as I experienced in Murrayville. There are a number of factors to take into account.

• What are the community’s needs?
• Who already provides services in the absence of a CAMHS?
• What can we as an Area Health Service plan for?
• What are the local community perceptions of what you may offered?
• What experiences have these communities had before?
• Who are the key people to involve?
• Why have other services been alienated within communities?

WHAT ARE THE COMMUNITY’S NEEDS?

Consultancy across a broad range of providers, consumers and carers is highly recommended by most strategic documents and planning processes. In the Far West generally the opening session of each public consultancy is identical in the issues raised. Employment, purpose for youth, family harmony and more services. But as one Health advisory Council meeting once asked me, How many psychiatrist hours do we really need in this community of less than two thousand people? If you break this down the child population would approximately 700. What are the psychiatrist needs for a school of 700? It was a great question and I still don’t know the answer. Often rural communities can be caught up in the mentality that they are under serviced and never stop to question what or how much of it they need and what the cause and effect outcomes are.
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WHO ALREADY PROVIDES THE SERVICE?

In the absence of professional service providers and agencies it is important to recognize who steps in to fill the gaps. Apart from extreme cases it is fair to argue that somehow problems get resolved in remote communities. A neighbor, a relative, a phone call or talk to an existing professional that may have some knowledge of the issue despite it not being their role. Is a nun an effective mental health worker? Can a GP provide a behavioural intervention to a conduct disordered child? Can a farmer help a fellow farmer through the death of a child? It is also important to recognize that these "fill ins" may provide an equitable service to what we could as an Area Health Service. Sometimes their philosophies and methods may not meet with our full agreement, but you tend to become more tolerant when there are few options.

The current emphasis on "mapping pathways to care" for health service consumers has raised a dilemma. Should the ‘Maps" only list professional services. What if a service the Area Health Service is to provide, is being provided by an untrained community member in their everyday social interactions? The best postnatal depression counsellor may be a shopkeeper who sits and has a "cuppa", the best parenting advisor may be an Aboriginal elder who takes the parent out bush for a chat and the best therapist for difficult adolescent males may be a sports coach. Should we map these informal service providers? If these services are being provided and as a health service we cannot guarantee a better, sustainable service then how do we compliment existing strengths without undermining or destroying the pre-existing ones. Should we be providing training and promoting these individuals as alternative services or informally providing them with information and allow them to continue their community role unpaid? Or should we actively promote the notion that anything but a professional service is fraught with danger? If we recognize and promote them, what are the legal implications for them and us?

If we set out to provide information to these informal service providers and they reject our input, what can or should we do? Do we take the high ground and promote ourselves as the only group with expert knowledge or do we take a medium term approach and hope that eventually the community comes around and sees things our way?

WHAT CAN WE AS AN AREA HEALTH SERVICE PLAN FOR?

As with many other health services providers throughout rural and remote Australia we have difficulty attracting and retaining experienced staff. In times of fiscal restraint with allowances and assistance being curtailed there is a financial disincentive to work remotely. Relationship, family matters, health care access and career opportunities are all factors that conspire to prevent the development of a stable sustainable rural/remote service. To retain a staff member for longer than two years is considered to be a successful appointment. Some positions may be vacant for extended periods of time despite several rounds of advertisements.

We can expect the majority of applicants to our clinical positions to be new graduates. This creates a unique set of dilemmas. They may be the sole worker in an isolated outreach clinic being expected to provide the spectrum of clinical, prevention and promotion interventions. In a tertiary CAMHS service it is unlikely that the same new graduate would be expected to undertake several years of close supervision before undertaking such roles and even then it is likely to be a multidisciplinary team approach. So how does a remote community respond to a new graduate? They are reservedly appreciative that the position has been filled and a different viewpoint can be accessed. However it is realistic to acknowledge that there are a large number of lay people in each community that are unpaid and have a greater skills base and experience than our new appointee. A twenty one year old graduate offering a parenting program alone to a robust group of rural parents is an ominous task. Some survive, few excel and some fall.

Therefore the reality of any development plan is to consider the positions may be periodically vacant and if filled, then be realistically only able to provide limited interventions. Each community is on a roller coaster ride that rises and falls with the appointment of various staff and their skills base.
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WHAT ARE THE LOCAL COMMUNITY PERCEPTIONS OF WHAT SERVICES CAN BE OFFERED IN A REMOTE SETTING?

When new staff arrive and announce their vision and plan for the community they are puzzled as to why they do not get an enthusiastic response. In time they learn that the community has heard it all before, promises made, grand plans developed, then abandoned and so the cycle goes. Programs or research projects are established, completed and move on. The community is asked to give information, bare their souls in the name of research or good planning and told how this program will benefit the whole community and then either they hear nothing back, the information is to academic and means little to them or is of no relevance at all. This is particularly relevant for Aboriginal communities.

So historically a polite mistrust of new staff has developed. In time, the agenda of the newcomer is revealed and the community reacts accordingly. The agenda of a new staff member may be career advancement, here to save the poor suffering citizens in the bush, seeking a life experience, a genuine interest in remote service delivery, hiding out from previous career mistakes or an inability to get along in a team situation. So why should the locals embrace the new comers and why shouldn’t they strive to maintain their own sustainable networks and roles? Unless you marry a local then you will probably leave!

As in the case of the northern Victorian town, a CAMHS service actually threatens the essence of small communities. Families. Why should they trust their most treasured asset to someone who may eventually abandon them not too far down the track? They also may have heard of, or actually experienced interference from a previous service provider. It may have been a local government youth worker who breezed into town proclaiming the rights of children in an over zealous way. As Australia often debates the merits of embracing American culture, rural communities debate the issue of being urbanized.

Regardless of the personal views of the worker or the philosophy of the agency, small towns have the ability to alienate or destroy any well developed program that may have been successful elsewhere. Things are personal and upfront in the bush. If a worker expresses a view that is too controversial, although it may be true, they risk their program failing. This process can be compared to the union practice of black listing. A recent example of this is the Sixty Minutes program on a remote NSW town and comments made by the school principal. Following this report students were withdrawn and a public meeting was held. So what was considered a progressive program was halted in its tracks and with no alternative education program to attend, students learning ground to a halt. A very concerted and conciliatory process is then required to recommence programs and ultimately it may mean the staff member must leave the community

This is not to say that programs must bend to local customs. It is important that local customs be recognized and understood in the given circumstances and adaptations and reasonable timeframes are designed to promote change if necessary. In order to effect change you must first gain an audience with the community and develop gentle debate. This may be deemed by some as wrong or inappropriate but the reality is that no change will occur if you are a lone voice in the crowd.

When a program is to be implemented in larger population centers the usual process is to seek out relevant and interested parties. A filtering process then occurs and partnerships are formed. In small communities there may be only one potential partner, it may be the school, the community health center or a GP. If a philosophical difference exists or there has been cause for past tension then the chance of forming a partnership is diminished. We do not have the luxury of self selecting partnerships. The same can be said for potential consumer populations. This places great demand on the few locally based services and it is important that prioritization be in the control of those services. An appropriate comparison would be that a metropolitan service be required to implement all of its programs in the confines of a few city blocks regardless of the demographics and if potential partners were willing or not. This working environment dramatically changes how you interact with other agencies. It tends to lead to a middle ground type working relationships as opposed to the strategic agenda.
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WHO ARE THE KEY PEOPLE TO INVOLVE?

This will vary from community to community.

IMPLICATIONS FORSERVICE DELIVERY

Area Health Services are responsible for providing the optimum care to its communities within its resources. In regards to CAMHS emotions, personal philosophies, community attitudes and appropriate resources complicate this notion. It is reasonable to argue that CAMHS in rural and remote areas have a broader psychosocial workload than larger specialized regional and metropolitan services. This is often due to a lack of other service providers locally.

Rural and remote Area Health Service need to take into consideration the following factors in relation to developing it CAMHS

• That we cannot guarantee consistent skilled CAMHS staff positions will always be filled in each team and therefore service sustainability and continuity.
• That members of the broader community may possess skills that compliment the programs we intend to deliver
• That the broader community may be better placed to deliver programs that are normally considered the domain of CAMHS
• That the FWAHS will plan to preserve the existing community structures that have maintained these communities at functioning levels
• That education sessions be open to all interested community members
• That remote CAMHS are more accountable to the communities they serve
• That compromise of traditional roles and responsibilities is inevitable and requires monitoring beyond the clinician
• That communities will ultimately determine the implementation and success of programs
• That new staff, external consultants and service providers require an orientation to remote "culture" and this is required prior to the commencement of any interventions or programs

On a final note may I suggest an exercise that may go some way to paralleling the planning role of services in remote settings. Try and plan a sustainable mental health service for a period of two years for 300 of your extended family, 100 of your line manager’s extended family and 100 of your neighbor’s family. The setting is an island 50 kilometers off shore, with a twice weekly boat service, limited health services. Imagine the permutations and combinations!

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Last Modified: 27-11-2002 10:11:50