“The mental health needs of African and Caribbean men is an area for public concern.”
Dr Frank Keating, a senior lecturer in health and social care wrote this in a 2007 Race Equality Foundation briefing paper. He was referring to the fact that this group are disproportionately represented in mental health statistics. Basically, African and Caribbean men have different experiences and outcomes when they come into contact with mental health services compared to other groups. These differences not usually being of a favourable kind. African and Caribbean men are more likely to be detained under the Mental Health Act, more likely to have come into contact with the mental health system through Police involvement, more likely to be placed in seclusion and less likely to be referred to mental health services through their GP (Keating (2007).
This over-representation of black men within mental health care was more recently confirmed by The Care Quality Commissions final ‘Count me in’ census, published in 2011. This annual census was put in place to support the Department of Health’s five-year action plan for improving mental health services for BME communities. In the census, Black men were again found to be at a disadvantage within the mental health system. Mind, the national mental health charity said it highlights ‘inexcusable racial inequalities’. They issued their statement immediately after the census results were published calling it ‘staggering’ that such ‘little progress’ has been made in reducing the mental health admission rates for BME groups.
How are black people portrayed and how are they treated within services? This is an important question, especially for statutory bodies. The Macpherson Report in 1999 saw to that. This was the result of the inquiry into the Police’s investigation of the murder of black teenager Stephen Lawrence. Institutional racism was said to exist within the Metropolitan Police and policing generally.
Institutional racism is not just an issue for the Police. The Government, courtesy of the Minister of State for Health at the time have already acknowledged institutional racism has existed within mental health care. This was stated in the 2003 National Institute for Mental Health in England document ‘Inside Outside. Improving Mental Health Services for Black and Minority Ethnic Communities in England’. The amended Race Relations Act 2000 then acted upon the Macpherson Report and placed a statutory duty on all public authorities to actively promote race equality (Commission for Racial Equality, 2004).
The 2003 ‘Inside Outside’ report argues that there is too much emphasis on institutional and coercive models of care. Institutional could be regarded as care that is more formal in nature and provided in facilities such as hospitals. Coercive meaning being forced, or being threatened with force to engage with and/or accept treatment from services. I do accept that this coercion sometimes is simply unavoidable, especially when there is a clear and present danger to someone’s health, or even life, be it the clients or someone else’s. The 2003 ‘Inside Outside’ report argues that to address health inequalities and institutional racism where it may exist within services, it is ‘essential’ to place community based mental health support at the centre of service development and delivery. This is not to dismiss the role of the statutory sector in providing this community based support. For example, there are Community Mental Health Teams (CMHT’s), assertive outreach, home treatment and early intervention teams that work in the community. This includes seeing clients at home. However, it does help highlight the important role the voluntary sector can play, not only in promoting mental health recovery for individuals, but also improving mental health services specifically for BME client groups. As already established, some of these groups (African and Caribbean men in particular) would have been much more likely to have experienced mental health services through formal and sometimes institutional settings (including being Sectioned or otherwise coerced into treatment) than say, their White British counterparts.
Professor Bhui (2012), a professor of cultural psychiatry and epidemiology argues that the voluntary sector is crucial in addressing race inequality in mental health care. He thinks the voluntary sector has made good progress in providing alternative options to minority groups that are at risk of receiving mental health treatment through coercive methods. This is a view also supported by retired consultant psychiatrist Suman Fernando (2003). He has a specialist interest in the relationship between mental health, race and culture and still writes regularly. He argues supporting the black voluntary sector essential in combating inequality. He calls this a ‘bottom-up approach”. In fact, The National Institute for Health and Care Excellence (2010) have incorporated into their updated Schizophrenia Guidelines the importance of mental health services working closely with local voluntary BME groups to ensure culturally appropriate psychosocial elements of treatment are delivered. This is important. It shows that the voluntary BME sector has officially been recognised as an evidence-based intervention in psychotic illness.
Having over ten years’ experience working in the voluntary and community sector (care and support) I have seen first-hand on many occasions the positive difference non-statutory sector services such as charities can have on engaging vulnerable people. This especially includes people with mental health problems who have not engaged with other services, especially if this is community based and involves visiting people at home, or in other non-institutional settings. As is stated by Hackney Council in their 2011 report on community mental health services in their locality, service users are instinctively drawn towards the voluntary sector more than statutory services. This is not to dismiss the role of, or effectiveness of NHS based mental health services. In fact, some of my most rewarding and best outcomes with clients have come as a result of working in the voluntary sector and linking in with statutory sector services (home treatment, assertive outreach team’s, GP’s and acute inpatient settings being examples).
As a first year mental health nursing student I will be working within statutory sector settings on placement practice for the next three years. I’m currently in an acute mental health ward. Possibly a career within NHS mental health services beckons. I will do my best to promote that nurses are well placed to make use of the BME voluntary sector. They do not need to be community based to do this. Care Programme Approach (CPA) meetings and formulation and/or discharge planning meetings are two examples I can think of that give ample opportunity for nurses to try and facilitate voluntary and community sector involvement, where appropriate and wanted by the service user, in their recovery. If we are to make a real and significant dent in how black men and other BME groups are represented in mental health statistics (i.e. get their type of contact and type of treatment from services on a par with other groups), there is a plethora of evidence, research and good practice guidelines indicating the voluntary sector is a vital cog in the wheel.
Adamson, J., Warfa, N. and Bhui, K. (2011) ‘A case study of organisational cultural competence in mental healthcare’, BMC Health Services Research, 11:218
Bhui, K. (2012) The voluntary sector has a role to play in reducing BME mental health detentions. Available at: http://www.theguardian.com/social-care-network/2012/oct/31/voluntary-sector-bme-mental-health-detentions (Accessed: 10 October 2013).
Care Quality Commission (2011) Care Quality Commission looks ahead as last Count me in census is published. Available at: http://www.cqc.org.uk/media/care-quality-commission-looks-ahead-last-count-me-census-published (Accessed: 10 October 2013).
Commission for Racial Equality (2004) Public Authorities and Partnerships: A guide to the duty to promote race equality. Available at: http://www.equalityhumanrights.com/uploaded_files/PSD/30_public_authorities_and_partnerships.pdf (Accessed: 7 November 2013).
Department of Health (2011) No health without mental health. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213761/dh_124058.pdf (Accessed: 10 October 2013).
Fernando, S. (2003) Cultural Diversity, Mental Health and Psychiatry: The Struggle against Racism. East Sussex: Brunner-Routledge.
Government Equalities Office (2010) Equality Act 2010: What do I need to know? A summary guide to your rights. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/85017/individual-rights1.pdf (Accessed: 29 October 2013).
Hackney Council (2012) Report of the Health in Hackney Scrutiny Commission: Community Mental Health Services. Available at: http://www.hackney.gov.uk/Mental-Health-Services-Scrutiny-Review.htm#.Umu6czfaJ8F (Accessed: 22 October 2013).
Keating, F. (2007) Better Health Briefing 5, African and Caribbean men and mental health. Available at: http://nmhdu.org.uk/silo/files/african-and-caribbean-men-mental-health.pdf (Accessed: 18 October 2013).
Mind (2011) Inexcusable racial inequalities unchanged in six years. Available at: http://www.mind.org.uk/news/4819_inexcusable_racial_inequalities_unchanged_in_six_years (Accessed: 10 October 2013).
National Collaborating Centre For Mental Health (2010) The Nice Guideline on Core Interventions in the Treatment and Management of Schizophrenia in adults In Primary and Secondary Care. Updated edition. Leicester: The British Psychological Society.
National Institute for Mental Health in England (2003) Inside Outside: Improving Mental Health Services for Black and Minority Ethnic Communities in England. Available at: http://www.devon.gov.uk/inside_outside.pdf (Accessed: 18 October 2013).
NHS Confederation (2013) Improving quality of care through culture change top priority for NHS leaders. Available at: http://www.nhsconfed.org/priorities/latestnews/Pages/Survey-suggesting-quality-of-care-not-priority-in-NHS-worrying.aspx (Accessed: 7 November 2013).
Papadopoulos, I. (2008) The Papadopoulos, Tilki and Taylor Model for Developing Cultural Competence. Available at: http://www.ieneproject.eu/download/Outputs/intercultural%20model.pdf (Accessed: 26 October 2013).
Read, J., Johnstone, L. and Taitimu, M. (2013) ‘Psychosis, poverty and ethnicity’, in Read, J. and Dillon, J. (eds.) Models of madness psychological, social and biological approaches to psychosis. East Sussex: Routledge, pp. 191-209
The Guardian (1999) Race: The Macpherson report. Available at: http://www.theguardian.com/uk/1999/feb/24/lawrence.ukcrime12 (Accessed: 14 October 2013)
Trawalter, S., Todd, A., Baird, A. and Richeson J. (2008) ‘Attending to threat: Race-based patterns of selective attention’, Journal of Experimental Social Psychology, 44:1322–1327
Alexander James Jones is a student mental health nurse. Prior to beginning his nursing studies he worked in social care mental health for several years. Follow him via @AJ628studentMH on Twitter