Monthly Archives: November 2014

Improving access to appropriate mental health services for BME communities

Unit for a syllabus: Improving access to appropriate mental health services for BME communities

Year 3 Report of “If only we were told…” Project

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Section 1

Year 3 of Project update 2013-2014

1.1 Decision to provide a Unit resulted from discussions with staff of University Departments and Colleges offering courses in Mental Health say that syllabuses already exist for their purposes. Birmingham City University exemplify City and Guilds Level 3 Certificate in Community Mental Health (for people aged 18-65 years) (ref 3056-31). Earlier on in this Project a member of staff from the Metropolitan College, Birmingham, had indicated that they would find a Unit addressed to the issue of use to them.

1.2 Although there are existing syllabi addressing Community Mental Health knowledge and understanding of issues such as “cultural competence” are assumed. Evidence cited below shows that there is little coherence in the concept although ideas are emerging. On the other hand it is evident that inequalities persist in mental health provision. “No Health Without Mental Health” was the flagship of the coalition government’s approach when they claimed that mental health would be given parity of esteem with physical health. A recent report states that while mental health problems are set to exceed those of physical health adding that their effects are more debilitating and cost the economy huge sums many are getting no treatment.

“only a quarter of all those with mental illness are in treatment, compared with the vast majority of those with physical conditions. It is a real scandal that we have 6,000,000 people with depression or crippling anxiety conditions and 700,000 children withproblem behaviours, anxiety or depression. Yet three quarters of each group get no treatment. One main reason is clear: NHS commissioners have failed to commission properly the mental health services that NICE recommend. The purpose of this paper is to mend this injustice, by pressing for quite new priorities in commissioning. This might seem the worst possible moment to do this, but that is wrong……This is mainly because the costs of psychological therapy are low and recovery rates are high. A half of all patients with anxiety conditions will recover, mostly permanently, after ten sessions of treatment on average. And a half of those with depression will recover, with a much diminished risk of relapse. Doctors normally measure the effectiveness of a treatment by the number of people who have to be treated in order to achieve one successful outcome. For depression and anxiety the Number Needed to Treat is under 3. In the government’s Improving Access to Psychological Therapies programme, outcomes are measured more carefully than in most of the NHS, and success rates are much higher than with very many physical conditions.”

How Mental Illness loses out in the NHS, LSE pp1,2 2012.

1.3 The provision of IAPT needs to be coupled with the assurance that it will be available for all across language and culture so that practitioners are able to be culturally competent. An IAPT document spells out the principles but no guidance is given on how this is to be addressed practically.

1.4 This year there have been some key conferences addressing BME mental health.

1.4 (i) The Joint Commissioning Panel for Mental Health services for people from bme communities report was launched at the Botanical Gardens, Edgbaston, Birmingham. Launch attended.

1.4 (ii) Birmingham City Council put together a working party and produced a document: Mental Health: Working in Partnership with Criminal Justice Agencies. (Download). This provides a protocol where agencies work together to ensure that vulnerable people are taken to a place of safety rather than end up in a police cell. In the African Caribbean community individuals disproportionally end up receiving coercive treatment for mental health problems. Meetings attended and input made.

1.4 (iii) Birmingham and Solihull Mental Health Trust launched a project “300 Voices” aimed once again at African Caribbean men. This looks like a replay of actions taken following the David Bennett Report 10 years ago. Could it be that this is reinforcing stereotypical views by focussing on inedividuals rather than the agencies where there is lack of understanding leading to misdiagnoses. It may be that it is institutions and practitioners that need to change their practices. Meetings attended and input made.

1.5 My personal experience of applying cultural competence to cases is very disappointing given the high claims made. Staff appear to be tasked with severe budget reductions and have little time or inclination to get involved in furthering measures to combat inequality. Cultural competence appears to be a remote concept to many staff with much indifference and denial of need. This reflects the situation described in the Francis Report on Staffordshire Hospital and the Winterbourne View account of care practice.

Section 2

Rationale for the Unit

2.1 This additional separate Unit encompasses principles and actions governing other Units of a mental health syllabus. In this case reference is made to the City and Guilds (C & G) Certificate in Community Mental Health (for people aged 18 to 65 years) levels 2/3. The soundness of what is in the syllabus is not questioned, rather it is intended to add a dimension addressed at dealing with diversity which may well be implied but evidence shows cannot be taken as read.

2.2 The Philosophy underpinning the C & G syllabus states:
(6.3 Philosophy) “The content of the Certificate is underpinned by the philosophy that to provide effective mental health services, practitioners at all levels need to understand the service user’s perspective. They should respect diversity and deliver appropriate individualised responses to meet the needs of service users. Effective practice is centred on the user and recognises and values the experience and insight of the service user in respect of his or her own mental health. Workers should enable and empower service users to enhance the overall quality of their lives, and should promote partnerships that service users find helpful.”

2.3 Background. The David “Rocky” Bennett Report (2004) made findings and recommendations which were taken up by the Delivering Race Equality (DRE) agenda and the Count Me In annual statistics for much of the next decade. Inequality and injustice was to be given added weight and media coverage with the publication of the McPherson Report on Stephen Lawrence.

2.4 The effects of “Race” and “Racism” and on individuals are still hotly debated .Diverse views range from the denial that they have an effect to the belief that experiences are integral to the lives of individuals. As shown in the reports on Bennett and Lawrence they may have a profound effect on the individual’s mental health. Denial of such experiences by professionals lead to misdiagnoses. The incidence of schizophrenia diagnosed for African Caribbean men for example is 6 times higher in the UK than anywhere else, including Caribbean islands. David Bennett’s experience is just one example where the Report itself questions whether the “schizophrenia” was a medical condition he suffered from, or a either a misdiagnosis of a condition brought on by the use of Cannabis. It is clear that Bennett had to deal with racial abuse in the description of events leading to his death. He had deal with a level of provocation that could seriously affect anyone.

2.5 During the next 10 years there have been many repetitions of David Bennett’s experience when African Caribbean men have died in custody. Disturbingly there is little sign that his report had made an impact on those dealing with such cases. Regrettably deaths in custody and violence to individuals have continued since the Bennett Report. Deaths of Mikey Powell and Kingsley Burrell, both African Caribbean men, in Birmingham following police intervention have been followed by prolonged periods where families have been left in the dark about what happened, all reminiscent of Bennett’s death. There have been many other examples across the country. While Mikey was known to have a history of mental health problems before the highly inappropriate police involvement Kingsley Burrell did not until he was taken into custody at the Mary Seacole Centre in Winson Green and sectioned under the mental health act.

2.6 A characteristic of the decade following Bennett that the focus remains on the African Caribbean community. This has lead to the ignoring of trends in mental health in other communities, some of which may share similar experiences to the African Caribbean.The work of such authorities as Sashidharan, Bhui and Swaran Singh has shown that their are considerable anxieties in South Asian communities. The earlier SCYS “Talk to Us Project” showed that many others shared these anxieties and faced problems in accessing appropriate mental health services.

2.7 Misdiagnosis. The term “schizophrenia” is associated particularly with African Caribbean men. The question is raised in the Bennett report whether he was misdiagnosed as a result of stereotypical views held by clinicians. A report from the US asks questions. This is an experience shared by many in BME communities.

“Racialized experiences have long been linked with the mental health and illness of Black people (See Fanon, 1952; Grier & Cobbs, 1968; Pierce, 1970). At the same time, integration of non-White minorities into majority White populations (a common feature of multiracial societies) arguably results in an increase in racialized experiences, and exposure to White racism. Of particular interest is the case of the UK, a country where the integration and assimilation of the Black population is particularly intense. This paper considers the role of the UK racial situation in the very high rates of schizophrenia found in the UK African Caribbean population.
Schizophrenia is the most chronically disabling of all the major mental disorders and typically affects only one percent of any given population. However, there is a six- to eighteen-fold elevated rate of diagnosed schizophrenia in the UK African-Caribbean population compared to Whites (Hickling, 2005). Moreover, the Black incidence rate of schizophrenia is higher in the UK than anywhere else in the world (Cochrane & Sashidharan, 1996).
The issue of extremely high rates of schizophrenia in African-Caribbeans in the UK has been a topic of interest to British scholars since the 1960s. However, much of the British research has been criticized with regard to its preoccupation with biological explanations for this issue (See Sashidharan, 2001). Indeed, it is only recently that sociological factors have been given recognition with regard to the dynamics of ethnic schizophrenia in the UK (See Boydellet al., 2001, Mallett, Leff, Bhugra, Pang & Zhao, 2002; Whitley, Prince, McKenzie & Stewart, 2006). In 2001, Boydell et al. demonstrated that the incidence of schizophrenia in non-White ethnic minorities in London was higher when they constituted a smaller proportion of the local population, indicating that social factors were having an influence on the elevated rate of diagnosed schizophrenia. Additionally, in 2002, Mallett et al. found that the rates of schizophrenia among African-Caribbeans in London were significantly higher than those in Trinidad and Barbados, again suggesting that social factors played a key role in the Black incidence rate of schizophrenia. In a similar vein, Whitley et al. (2006) demonstrated that mental illness was greater among minorities in areas where they comprised a smaller proportion of the population.
While the above research studies indicate a willingness to consider how society may play a role in ethnic schizophrenia, there is a lack of discussion on how “racialized experiences” could be influencing the elevated rates of diagnosed schizophrenia. For example, while Mallet et al’s (2002) study draws attention to the importance of social factors in the high rates of schizophrenia in African-Caribbeans in the UK, there is little reference to African-Caribbeans as “racial minorities”, and the role that racism might play in the Black incidence rate of schizophrenia. While their research highlights the significance of “social disadvantage” as a cause of severe mental illness, Mallet et al. (2002) focus on issues such as unemployment, and on individuals who had been separated from one or both parents during childhood.
It is argued here that more attention needs to be given to the experience of African-Caribbeans as racial minorities with regard to this topic. As Jamaican scholar and psychiatrist, Frederick Hickling (2005) points out, the evidence regarding the Black incidence rate of schizophrenia is shifting in favor of factors of social alienation and racism experienced by Black people in the UK, and to misdiagnosis by White British psychiatrists. Hammack (2003) notes that an individual’s minority status represents an intrinsic stressor, and Bhugra & Ayonrinde (2001) draw attention to the idea that racism is likely to act as a chronic stressor, and that chronic racism may well precipitate psychiatric disorders. Moreover, it has been suggested that psychiatry as a discipline is inextricably linked with racism (See Littlewood & Lipsedge, 1982; Fernando, 1988; Sashidaran, 2001; Timimi, 2005); as such racial bias in psychiatric diagnosis might also be an important factor in the Black incidence rate of schizophrenia. For these reasons, racialized experiences (racial minority status stress, racism-induced stress, and racial bias in diagnosis) need to be seriously considered in the analysis of the elevated rate of diagnosed schizophrenia in the UK African-Caribbean population.”
Racializing Mental Illness: Understanding African-Caribbean Schizophrenia in the UK by Clare Xanthos, M.Sc., Ph.D., Senior Researcher National Center for Primary Care, Morehouse School of Medicine, Atlanta, Georgia. Abstract.

Consideration must be given to institutionally racist views and practices in psychiatry. The following article discusses this:

“Although the debate about race and psychiatry is as old as psychiatry itself, it is only in the past three decades that the psychiatric institutions and practices in this country have come under critical scrutiny for their racial bias. During this period, much has been written about the experience of Black and other ethnic minority groups within psychiatry and the tacit acknowledgement that there is a problem about race within British psychiatry appears to be shared by psychiatrists in general. There have also been many attempts in recent years to make mental health services more culturally aware and sensitive. How we provide better services for Black and other ethnic minority groups has become a service priority in many areas.
Despite the commitment by both professionals and managers to provide ethnically sensitive and culturally appropriate services the overall experience of psychiatric services by Black and South Asian people in this country remains largely negative and aversive. The disparity between ethnic minority groups and White people in service usage, service satisfaction and outcome persists with little to suggest that the situation is likely to change. In fact, there is no single aspect of contemporary psychiatric care within which Black or South Asian people are not disadvantaged.
One conclusion that we can draw from all this is that the various changes and innovations around ‘ethnically sensitive services’ have largely failed to address problems with race and psychiatry. Perhaps the practical emphasis placed on improving services for particular ethnic groups has distracted us from the more fundamental but also the more difficult task of addressing racism within psychiatry. In other words, until we begin to address racism within psychiatry, in its knowledge base, its historical and cultural roots and within its practices and procedures, we are unlikely to achieve significant progress in improving services for minority ethnic groups.”
Institutional racism in British psychiatry †S. P. Sashidharan, Professor of Community Psychiatry and Medical Director

2.8 Experiences of Asian and other BME communities. The virtually exclusive focus on mental illness on African Caribbean communities ignoring the experiences of other groups has led to increasing assertion that much need is
not being met. The “Talk to Us” Project met with representatives of many other communities each of whom spoke of problems being faced by them. Somalian and Bosnian communities included many who had experienced the trauma of wars and forced displacement. Others, including South Asians, said that what was being said about the African Caribbean community was recognisable to them, including access to appropriate mental health services. This was discussed in the second year report of the current Project “If only we were told…” (a comment made by Dr Joanna Bennett, sister of David, echoed by many since). See section 4.

2.9 The history of “cultural competence” in relation to health care is coupled with a patient-centred approach in a brief history of this in relation to health care in the US. While these aspects are also familiar in the UK it is more difficult to trace a coherent approach.

2.10 A model showing an iceberg, with matters commonly regarded as being the essence of “Cultural Competence” reveals the complex nature of the subject, with the hidden aspects affecting an individual’s understanding of life being subject to self-concept, position in family, values etc. These aspects cannot be captured within formulae since they will be particular to the individual concerned, although within a framework of the specific culture, within its traditions and histories. This has at first to be recognised if not immediately understood. Understanding can only be gained by interacting with the individual, their family and community. While here may be factors presenting problems, there are also traditional support networks existing in communities which could provide considerable help.

2.11 Kamaldeep Bhui and others examined courses promoting cultural competence in 2007 and only found few courses in North America that met their criteria. They were looking for courses which had been evaluated to show that outcomes were effective in improving competence. Bhui cites the report into the death of David “Rocky” Bennett (download) as a call for training in cultural competence for health workers, but outcomes for BME communities remain the same as before. While there appear to be many scattered attempts at making improvements funding crises have led to statutory care agencies failing to act while many voluntary organisations (some 40 documented in the earlier SCYS “Talk to Us” Project report in the West Midlands) have lost the capacity to help if not closed. This is spite of the current Government’s “No Health without Mental Health” document which recognises the persistence of serious inequality in appropriate service provision affecting BME communities.

2.12 While “Cultural Competence” is widely spoken of but in reality there is little coherence in course provision with little evidence of their effectiveness, although there are individuals in the UK who are trying to change this. At present it is necessary to look to North America for a more sustained approaches, although “Cultural Competence” courses are coming into favour in the world of business. When it comes to the imperative of profit rather than health there appears to be a greater enthusiasm to grasp principles. Is there something to learn from this?

2.13 Talking Therapies
Many people from BME communities have said that they have been unable to access key developments on mental health, including talking therapies such as Cognitive Behavioural Therapy. Governments have shown interest since early findings were that such therapies could be as effective as medication in appropriate cases. It was announced that Newham would be the place where developments would be trialled on giving access to BME communities. This was 2006-7. Newham’s current website gives information on their Talking Therapies services but it is not immediately apparent how accessible it continues to be in addressing equality. The one aspect which stand out as important in the ability to make self-referrals, a declared barrier in the past.
As with other treatments it is necessary for practitioners to be fully aware of cultural understandings relating not only to individuals but to families and community because of a key difference between nuclear and extended family practices and understanding. In the west it is usual for individuals to decide on action they take without necessarily referring to anyone else, whereas in Asian cultures, for example, actions are taken within the context of family and may impinge on relationships with a number of people, all of whom have beliefs and expectations. It is often assumed that those expectations may be negative and unhelpful, but it is wise to consider whether traditional support may be just what is needed by the individual concerned. In this respect agencies, families and communities need to work together.

A report on BME counselling in Devon is worth consulting as it appears to promote a considered approach.

2.14 What is on offer here is a unit considering factors which will act as a guide to ensuring that groups identified as receiving less favourable, or no treatment, can be directed to appropriate services that meet their needs and help their families and communities develop support networks in partnership with statutory bodies. Earlier reports “If only we were told” (Year 1) and “Cultural Competence” (Year 2) made links to many reports and articles relevant for students following this Unit. The two reports can be seen at the Project website with the warning that some of the links need updating where reports have been removed.

2.15 The Unit is modelled on City and Guilds Level 2/3 Certificate in Community Mental Health Care (for people aged 18-65 years).
Level 2:
Level 3:
The Unit however may be regarded as stand alone or be used with other courses for training, particularly with regard to Cultural Competence.

Section 3

Unit: improving access to appropriate mental health services for BME communities.
Level 2/3

Outcome 1 To consider how diversity in language, culture, ethnicity and experience vary individual and community’s concepts and understanding of mental illness.
The candidate will be able to
1. understand how the experiences of BME communities affect their lives and particularly how this can be a factor in mental illness
2. understand recommendations of key reports on those who have had poor experiences of living in Britain because of their “race” and ethnic origins eg David Bennett and Stephen Lawrence
3. consider their own beliefs and values regarding “race”. ethnicity and religion, recognising stereotypical views and ideas resulting from our colonial history
4. listen to the experiences of individuals from diverse background non-judgmentally.
Outcome 2 For providers to recognise the need for understanding the aspects of cultural competence essential for providing an appropriate service
The candidate will be able to
1. know with actions which followed for 10 years following the David Bennett Report in 2004
2. assess factors for failures to fundamentally alter the situation of intractable inequalities continuing after 10 years addressing the issues raised
3. understand the views and feelings of other members of BME communities and their ability to access appropriate and effective mental health services
4. understand what aspects of “cultural competence” need to be recognised and understood i.e. in the “iceberg model” is hidden factors which are crucial for consideration rather than superficial knowledge about different cultures

recognise why many from BME communities don’t come forward for help, or are unable to access appropriate services
Outcome 3 To assess how developing talking therapies such as CBT can be accessed by and delivered to people across languages and cultures.
The candidate will be able to
1. consider how effective talking therapies can be offered to those with different languages, cultures, religions etc.
2. take account of involving family members and communities in helping deliver support to individuals in need
3. examine cultural assumptions underlying such burgeoning remedies as Cognitive Behaviour Therapy (CBT) and be prepared to modify their approach
General outcome: The candidate will be able to apply principles appropriately throughout the syllabus. (City an Guilds Community Mental Health Certificate level 2/3)