The APS Grant for Intercultural and/or International Projects of up to $10,000 supports innovative projects that have an intercultural or international focus, particularly in countries where psychology is an emerging discipline. Dr Lisa Phillips MAPS from the University of Melbourne was awarded the APS Grant in 2008-9. Her project aimed to improve the mental health literacy of the Palauan community, taking into account traditional lay beliefs about mental illness, and the level of stigmatisation of the mentally unwell.

The Republic of Palau is an island nation in Western Micronesia 800 km east of the Philippines and 3,200 km south of Tokyo. The population is approximately 21,000, of whom 70 per cent are native Palauans of mixed Melanesian, Micronesian and Malayan descent.

How did you come to be involved with the project in Palau? What was your role?

In 2001 I met two researchers from the University of Utah at a conference in Canada. They had been working in Palau for five to ten years primarily mapping family pedigrees of schizophrenia. The prevalence rates of schizophrenia and psychosis within Palau were already known to be about double the rates usually cited elsewhere, likely due in part to Palau being so geographically isolated (until the advent of modern travel there was little contact with other islands and therefore a limited gene pool). The researchers I met were shifting their focus to children and beginning to investigate whether it was possible to identify those at highest risk of developing a psychotic disorder. They were aware of my work at the PACE (Personal Assessment and Crisis Evaluation) Clinic in Melbourne investigating similar questions locally, and evaluating interventions aimed at reducing the transition to psychosis, or at least reducing its impact on those who did become unwell. Together we thought it would be terrific to apply aspects of that work in Palau. I was keen to be involved but it wasn't until a few years later that I managed to travel to Palau to meet potential collaborators and Palauans involved in the health system to discuss what might be possible there.

The outcome of that visit was that the University of Utah researchers, the Palau Ministry of Health and I obtained a National Institute of Health/Foley grant to train local Palauan counsellors in psychological interventions that might be effective for young people at heightened risk of developing a psychotic disorder, and to evaluate the intervention. My primary role was training and supervising the Palauan clinicians. Since then I have been fortunate to travel to Palau several times and have got to know many Palauans involved in the provision of mental health services as well as health administrators. Together with my US colleagues, I have also engaged in regular telephone supervision sessions with the Palauan clinicians. In addition to that project, most recently the APS Grant enabled me to travel to Palau to conduct mental health training and education sessions for other Palauans who may encounter young people experiencing mental health difficulties, in an attempt to enhance understanding and reduce stigmatisation.

What personal qualities and professional skills were most valuable to you during that time?

The most important thing has been an openness to learn about Palauan culture and to adapt my expectations about how psychological interventions should be implemented and supported - there are no psychologists in Palau, and we worked with nurses and school counsellors with varying levels of prior training. Traditional healers remain very active, treating everything including mental health issues, so learning about these practices and being able to work effectively beside them was particularly important. Patience has also been important, recognising that things take time in a place where resources are scarce and stretched. But knowing clinicians and heath administrators are there who are keen to improve the mental health of the Palauan community has been fantastic.

What has the experience meant for you as a person and as a psychologist?

Going to Palau was my first trip to a developing nation. It has been jarring at times to be in this glorious tropical paradise, staying in my nice hotel and knowing that people close by are living in a corrugated iron shack with a dirt floor. Yet not all Palauans live in those conditions, and I have become increasingly aware of the conflict that countries like Palau experience - wanting to develop economically yet also wanting to retain their unique culture. Palau is also in an interesting position politically, as an independent nation and a member of the United Nations. It has close financial and defence ties with the United States but has established diplomatic relationships with other nations as well. For a small country it has made some big statements involving anti-whaling, adopting the world's first nuclear-free constitution and providing asylum for former Guantanamo detainees. It has been interesting seeing some of these events unfold and speaking to Palauans about these issues. Everybody I have met there has been extremely generous with their time and willingness to educate me about their country and their culture.

As a psychologist, the experience of working in Palau has really brought home the importance of trying to understand and acknowledge the cultural diversity of clients.

How did the APS Grant for International and/or Intercultural Projects assist you in your work in Palau?

The APS Grant enabled me to travel to Palau in November 2009 to conduct educational sessions aimed at improving the mental health literacy of the Palauan community. Mental health literacy refers to knowledge and beliefs about psychological health and illness, and is thought to influence help-seeking behaviour. This concept emphasises public knowledge, recognising the central role of individuals in addressing psychological difficulties they or others close to them experience. The education sessions were very general, aimed at people working in areas in contact with the wider Palauan community. Attendees included police, teachers and early childhood workers, people aligned with various faith-based organisations and representatives of welfare organisations.

The session content aimed to dispel common myths about mental illness and stimulate discussion and thought about its causes and treatment. The aim was not to provide participants with training in diagnosis or treatment of mental health difficulties. We hoped that participants would be more aware of the complexity of mental health and illness and perhaps better able to recognise when someone (or they themselves) might require assistance. Basic strategies aimed at facilitating access to appropriate clinical services were provided at the end of the session, together with self-care strategies. The sessions were structured to facilitate discussion that encompassed traditional Palauan beliefs about mental health and the role of healers. Interestingly discussion focussed most on beliefs about causes of mental illness, and about perceptions in Palauan culture that might be associated with perceived increases in the incidence and prevalence of mental health problems amongst young Palauans. Attendees contributed generously to the discussions, reflecting on their own experiences or those of family and friends.

The APS Grant also enabled me to meet key people within the Palauan Government and potential sponsors to discuss ongoing work there and in the wider Pacific region. This work will be aimed at training health professionals to better recognise and treat mental health issues, as well as identifying opportunities for further mental health literacy education for the wider population.

What are some immediate and/or longer term mental health and wellbeing issues confronting the people of Palau?

A key issue faced by Palau - and many other developing countries - is the challenge of embracing opportunities for development whilst also encountering and dealing with other influences from contact with other countries. Palau has seen a huge increase in substance use levels over the past decade since travel has become easier. Suicide levels have also increased, particularly amongst young people. Many Palauans attribute these changes to contact with Western nations and the conflict that has developed between traditional Palauan culture, which is very family oriented and collectivist, and more Western individualistic ideas.

Also concerning is the difficulty countries like Palau have in attracting and retaining appropriately trained mental health clinicians. Many young Palauans travel to the US for their education and often do not return home to live because they receive higher salaries elsewhere. Whilst this is understandable, it leads to workforce shortages to address the many issues emerging within the population.

Is there a take-home message for us as psychologists here in Australia, and as global citizens?

Whilst visits by international researchers and clinicians are largely welcomed and highlight the needs of developing countries like Palau, the infrastructure and funding to facilitate long-term change and improvement in services is not always available. Therefore the aim of the Palauan government and of foreign aid and funding sources is to strengthen local resources to eventually reduce the reliance on external support. I hope last year's opportunity to provide training will translate into an ongoing involvement in strengthening the Palauan and Pacific health systems.

Interested psychologists should lobby aid organisations to fund programs to support the development of mental health services in developing countries in our region. Australia's mental health services are well regarded internationally and we certainly have expertise in training and service development which could be used to support other countries. I would certainly also encourage psychologists to take up any opportunity that comes your way to be involved in psychological work in other countries, as the benefits for those countries as well as for you personally can be enormous.

Thanks to Heather Gridley for conducting the interview.

InPsych June 2010