INTRODUCTION

Older people experience a broad range of mental health problems and contact with specialist mental health services is increasing. This contact brings a desire on the part of consumers and carers to have greater participation in the management of these services so their unique needs are better addressed. The population served by older persons’ mental health services (OPMHS) is different from other mental health services. One of these points of difference is the greater presence of other people involved with the care of the older person, be that a spouse, a child or a neighbour. Many people derive a lot of satisfaction from being a carer and they are a very valuable resource, but recognition needs to be given to this role, and also the issue of carer burden and ways to reduce burden.

CONSUMER AND CARER PARTICIPATION IN MENTAL HEALTH SERVICES

Since the early 1990s, beginning with the National Inquiry into Human Rights of People with Mental Illness (Human Rights and Equal Opportunity Commission 1993), there has been a considerable shift in philosophical thinking about consumer and carer participation in mental health services. No longer is their presence a neglected, unsupported and almost invisible group of family members struggling to deal with the impact of mental illness on their lives (Mental Health Council of Australia and Carers Association of Australia 2000). Consumer and carer groups have developed into highly structured, funded organisations to achieve their purpose of support and advocacy for consumers and carers.

All the current government policy documents have a consistent and strong reference to the importance of consumer and carer involvement in the management of mental health services to the extent that it is listed as a quality indicator (Australian Health Ministers 2003, Australian Health Ministers Advisory Council 1996). The input of consumers and carers extends from direct involvement in the mentally ill person’s treatment and care plan through to the broader areas of service planning, delivery and evaluation. Beyond being a major stakeholder, another reason why consumer and carer input is important is because their perceptions of what is important in a mental health service can differ significantly from that of the service providers. Lelliott et al (2001), for example, found that consumers placed greater value on social and staff relationships as well as purposeful daytime activities, rather than having all attention focused on controlling their symptoms.

How ‘participation’ is defined and implemented will determine the feasibility of participation. Indeed, barriers to consumer and carer participation do exist, and these have to be dealt with on an ongoing basis. Some consumers and carers do not want to be involved as they have other priorities in their lives. There may be a considerable amount of family conflict and ill-feeling where the carers may not want involvement, or the consumer may not want their carer involved. Geographical distance, not speaking the dominant language or having compromised health status themselves could be other barriers for carers. Additionally, some mental health service staff may resent consumer and carer participation or have issues with privacy and confidentiality. Knowing the barriers and working out strategies to overcome these will empower consumers and carers so their participation is maximised.

Integration of consumer and carer input for mental health service delivery needs to be facilitated. This is essential so that tokenism is avoided and the benefits realised. Facilitation involves delineating the participation role and educating staff and other carers and consumers about the role and how it articulates with the service. The consumers and carers themselves need to have training and support on how to participate effectively as well. Lloyd and King (2003) have provided ideas for a broad approach to maintain the momentum for consumer and carer participation. The ideas include multidisciplinary and service discussions about strategies to continually improve partnership, creating links between government and non-government sectors, distributing promotional material, incorporating consumer and carer participation into service plans and policy and procedure documents, conducting joint research and evaluation, encouraging working party and committee membership, conducting multidisciplinary and service forums, and involvement in staff education and training. The paid employment of carer and consumer consultants in mental health services has been a successful strategy. These consultants draw on their experience and that of other consumers and carers. They can have an array of roles in areas such as advocacy, education, management and research.

SUPPORT

It is well known that recovery from mental illness is enhanced with support from family and friends. For family and friends to maintain these roles, they in turn need support. Support can come from the mental health services, which can provide information and ready communication. Support also comes from consumer and carer organisations, which to their credit have become very effective organisations in a relatively short period of time. This effectiveness has been achieved through their being able to identify and assist with the specific needs of carers, and lobbying and representing on behalf of carers. Below are listed some of the consumer and carer groups that function at a national level, with many local branches throughout the country.

SPECIAL CHARACTERISTICS OF OLDER CONSUMERS

The consumers of community mental health services for older people have a different profile from consumers of other adult mental health services. Foremost are the physical changes and medical comorbidities that are associated with old age and how these interact with mental health problems. This interaction is complex because psychological distress can cause or exacerbate physical problems, and physical problems can exacerbate psychological distress. As a consequence, the mental health worker requires several things: a sound knowledge of pathophysiology; an understanding of how this pathology may influence mental health problems; and the skills to monitor such situations.

From an emotional perspective, older people usually have more mature cognitive processes that have developed from many years of interacting with other individuals from a variety of backgrounds. They will often have more understanding and hence more control over their affective states. Their life focus also changes from the time they have lived to the time they have left to live.

Help-seeking behaviours for the present cohort of older people are also changing and are likely to continue to change for the foreseeable future. Previously, older people might have sought help from their general medical practitioner, a friend or from the clergy. However, increasingly, they are becoming comfortable with acknowledging their mental health concerns and are more willing to seek help from mental health specialists. Although many different mental health problems affect older people, they often present in a superficially similar manner. This can make it difficult to arrive at an accurate diagnosis and prescribe the correct treatment.