The Ten Essential Shared Capabilities Module 5:

Race equality and cultural capability

Author: Peter Ferns
Original Authors: Errol Francis with Ian Gittens It is estimated that there are over 6 million people in England who are designated as from black and minority ethnic groups. Black, Irish and other minority ethnic groups experience high levels of social and material deprivation when compared with the majority white population. (Inside Outside, 2003, Department of Health, page 9) Welcome to Module 5. It is designed to help you explore the links between the Ten Essential Shared Capabilities and race equality and cultural capability. Key ESC Elements: Respecting Diversity, Challenging Inequality, Providing Service User Centred Care, Making a Difference. After completing this module you will: Be aware of the history and background to the experience of Black and Minority Ethnic (BME) mental health service users Understand the connections between the broad themes relating to race, culture, oppression, mental health, the Ten Essential Shared Capabilities and your personal practice Understand and be able to apply a number of key terms and concepts within the race, culture and mental health debate Understand the importance of organisational as well as individual change in relation to delivering race equality

Contents
1. Approaches to Race Equality and Cultural Capability (RECC)................... 2 2. Defining some fundamental ideas in RECC................................................ 7 3. Key factors in Black and Minority Ethnic (BME) mental health ..................11 4. Breaking the Circles of Fear.......................................................................20 5. Delivering Race Equality.......................................................22 6. Links to further learning...............................................................................24

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1. Approaches to Race Equality & Cultural Capability
The first step towards achieving race equality is to become more aware of problems that exist for BME people in your service. If you do not recognise a problem it will never get addressed. Awareness depends on how reflective practitioners are and how well a critical analysis of service provision is conducted.

Activity 5.1 Looking at where individuals are coming from

How would you analyse these common statements? Write your responses in the right-hand column. 1. We dont have any Black people around here so its not a problem. 2. BME people should fit into our culture and then they would have fewer difficulties with services. 3. We just need to learn more about and respect other peoples cultures and we will then tackle racism effectively. 4. It doesnt matter to me what colour people are I treat everybody the same. 5. If you get more BME workers in the service we will be able to meet the needs of BME service users. 6. Institutional racism is such a big problem there is very little that I can do about it. 7. We just dont have enough resources to provide a specialist service to BME people. 1.

2.

3.

4.

5.

6.

7.

If you are doing this activity in a group discuss your answers with two other people. Compare what you have written with our grid on the following page.

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Our grid
1. We dont have any This statement makes an assumption that racism exists only Black people around here if Black people are present this is not true. It could be that so its not a problem. racism is a bigger problem where there are only a very few BME people. Racism, as with other forms of discrimination, merely throws a spotlight onto general problems and weaknesses within a service so race equality is about good practice for all service users. 2. BME people should fit into our culture and they would have fewer difficulties with services. This statement begs the question about who defines our culture and whether it can be defined in such a way. All cultures are complex and comprised of many different cultural influences, there has always been mixing and combining of cultures throughout the ages. Furthermore, most Black people have been born here and are fully part of British culture but still experience discrimination on the basis of skin colour and appearance . Furthermore, the approach here displays a degree of cultural arrogance in assuming that the dominant culture has nothing to learn from other cultures and so this is an assimilation approach. This statement is essentially a multicultural approach. It assumes that education and a rational approach will be sufficient in tackling racism but many aspects of prejudice and discrimination are not rational. It also assumes that knowledge gained by the individual will be used to reduce discrimination just knowing about culture is not enough to tackle racism. Knowledge about the varieties of ways in which racism is manifested could help but knowledge alone does not necessarily change behaviour or impact on discrimination, power and structural inequalities in society must also be taken into account. This approach is colour-blind and assumes that equality is about treating everybody the same but we are all different with different needs. Equality is about equal respect but not necessarily the same treatment. A persons skin colour may well be an important aspect of that persons identity and life experience and denial of its significance devalues the persons view of their reality in society. The statement displays an assumption that any BME workers will be able to meet the needs of BME service users merely because of their race or ethnicity this is too simplistic. The needs of BME service users may not be met by BME workers if they do not have the necessary knowledge or skills.

3. We just need to learn more about and respect other peoples cultures and we will then tackle racism effectively.

4. It doesnt matter to me what colour people are I treat everybody the same.

5. If you get more BME workers in the service we will be able to meet the needs of BME service users.

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6. Institutional racism is such a big problem there is very little that I can do about it. This statement suggests that individual practitioners are powerless and can do little to challenge institutional racism. Race equality starts with the individual commitment of practitioners and with them taking accountability for their own practice. The experiences of service quality of BME service users are often determined by the practice of the individual practitioners dealing with them. The statement excludes BME service users from the mainstream of mental health services, marginalises them and denies people a fair share of resources. BME people are taxpayers and contributors to society as much as any other group of citizens. There is also a suggestion here that BME people are extremely different in their basic needs compared to other service users which is not true.

7. We just dont have enough resources to provide a specialist service to BME people.

Now answer the following questions: What kind of things have you said about RECC issues in the past?

Do you still believe in what you said?

If you have altered your views what helped you to shift your thinking?

Activity 5.2 Looking at where your service is coming from?

Look at the following statements and put a tick against the one(s) you feel most represent your services approach to issues of Race Equality and Cultural Capability. 1. Institutional racism is not seen as serious or widespread as the Government makes out and it seems that most people in the organisation feel that too big a fuss is made about it. 2.People accept that institutional racism exists in many mental health services but most people say that they have not really come across it at all in their services. 3. People know institutional racism is a widespread problem in mental health services but it is felt that services are doing the best they can given the resources.

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4. It is generally felt that institutional racism is a problem in every mental health service but most people feel that they have addressed it in their service and so its not a big problem anymore. 5. People feel that it is fine to look at BME issues in mental health but it is felt that some perspective has been lost as there are other issues of equality which are thought to be even more important, such as gender issues or poverty. 6. People can see that institutional racism is a big problem in mental health services and that they need to improve things but they cannot see how they can directly influence change. 7. The service has found out about BME peoples experiences of services and has talked to service users and families directly. Institutional racism is also discussed amongst colleagues but it is felt to be such a big problem that people dont know where to start. 8. Most people have been careful to reflect on their practice and look out for instances of racial discrimination in services. People have recorded things, gathered evidence of problems and fed it through to management but nothing seems to have come of it. 9. Some teams have formulated action plans to promote race equality and they have set tasks to tackle problems and gaps for BME people in the service. They feel that once they achieve their goals they will have improved the service. 10. Team action plans to improve services for BME people are part of a wider Race Equality strategy that everyone has contributed to in the organisation. There are regular reviews and monitoring about what is being done in the organisation to achieve continual improvements over the long haul. Once you have finished ticking the statement(s) to record where your service is, read about the Race Equality Scale on the next page.

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The Race Equality Scale
1 Hostility Sometimes people may be hostile due to anger at being accused of being racist as it is perceived by them. More often, it suggests a failure to recognise institutional racism as a problem at all. Trainers who try to highlight institutional racism are presumed to have a hidden political agenda and White trainers who do this are somehow betraying their own people. This response may recognise that institutional racism exists elsewhere but not here. People will claim that there are no problems with their services in relation to BME people even when presented with evidence to the contrary. If people in denial are pressed harder they may enter into a hostile response instead. This response essentially does not view institutional racism as being all that bad and discrimination is seen as unavoidable. Individuals who experience racism are expected to accept it and make the best of their situation. Service change is seen as being too hard or unrealistic. Apathy is arguably the most effective driver of institutional racism as people with power and influence in services need only be apathetic and not question discriminatory systems, policies, procedures and organisational cultures for institutional racism to thrive. In other words, practitioners do not have to be actively racist to racially discriminate they just have to be apathetic and the system discriminates. In this response people recognise there is a problem with racism but deal with criticism by claiming that problems have been addressed when they have not. People may exaggerate small steps towards progress or take credit for a few excellent agencies in their area whilst not tackling serious problems within the majority of local services. The net effect of this response is to increase the hidden nature of institutional racism leading to tokenism and the creation of further barriers to progress. People engaging in this response recognise that institutional racism is a problem in services but they will deflect criticism about racism by claiming that other forms of discrimination are worse such as sexism or discrimination against disabled people. A hierarchy of oppression is constructed in peoples minds which is both divisive and does not lead to a coherent value-base for equality as a whole. Another response following recognition of the problem of racism could be one of puzzlement at what to do about it. People may express feelings of being deskilled and unconfident about dealing with BME people. There may well be a desire to improve practice but lack of clarity about how to do this.

Denial

Apathy

Pretence

Avoidance

Puzzlement

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7 Acknowledgement This response demonstrates a degree of empathy for BME people on the receiving end of discrimination. It actively communicates awareness of institutional racism and affirms the experiences of BME people. However, acknowledgement does not necessarily lead to actual improvements. Practitioners actively monitor for discrimination, record experiences of BME people and gather evidence to analyse the patterns of discrimination occurring in services. However, analysis does not guarantee that changes will happen. In this response practitioners and managers act on their analysis, formulate action plans to address problems and gaps in services for BME people and carry out their plan to achieve the targets/goals set. Here action plans are coordinated through a wider race equality strategy across the whole organisation and local community and they are regularly monitored. A series of action plans are carried out over a period of time to achieve ongoing improvements.

Analysis

Action

10

Sustained Improvement

Tick where your Service/Team is as a whole on this scale.

1 2 3 4 5 6 7 8

10

Now answer the following question: What would your Service/Team have to do to improve its position on the race equality scale by at least one step?

If you are doing this activity in a group compare your ratings with your colleagues. Discuss any differences in your ratings and what your evidence is for your judgements.

2. Defining some fundamental ideas in RECC

They didnt really take my culture into account One nurse told me to think of Rama and line up for my medication. (Asian Woman service user, Ferns, 2003) The concept of culture is very important but it is also quite complex. Here we will look at how culture and power can combine to create oppression and discrimination (see diagram
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below). In every society people are born with or acquire differences in their lives and the way power is used in that society influences the meanings given to differences. So, people can be born with differences such as a particular appearance, skin colour or physical impairment but may acquire differences in beliefs or values through their cultural context or they may acquire a physical disability through illness or accident. The beliefs and assumptions can be positive or negative and quite often people do not require any evidence to hold them these are prejudices that influence the values assigned to individuals and the social groups they belong to. Once different values are assigned regularly to certain social groups over time they begin to generate positive or negative stereotypes about these groups. For instance, people who attend university at Oxford or Cambridge may have a positive assumption made about them that they will be good leaders or people who are homeless may have a negative assumption made about them that they have brought their situation upon themselves. The power structures within society which help create prejudices and stereotypes then incorporate them into the structures and systems of organisations and services that affect peoples life opportunities; such as education, health, employment and mental health. The process leads to easy access for those positively stereotyped and unfair barriers for those negatively stereotyped. Ultimately some social groups enjoy privilege whilst others are subjected to oppression neither outcome is desirable as they are both based on unfairness and social injustice. Racism as a form of oppression then operates at an individual level with prejudices and stereotyping influencing relationships and communication between practitioners and service users. Racism at an organisational level influences services through stereotypes and reinforces them through policies, procedures and systems contributing to institutional discrimination. Racism at the societal level creates discriminatory power structures and maintains stereotypes; it supports discriminatory organisations through poor policy implementation and further strengthens institutional discrimination.

P e o p le b o rn w ith o r a c q u ire d iffe re n c e s in th e ir liv e s P re ju d ic e s

P o s itive B e lie fs N eg a tive B e lie fs

S te re o typ e s
P o s itive V a lu e s Easy a c c es s N eg a tive V a lu e s U n fa ir b a rrie rs

U n fa ir a d va n ta g e s

In s titu tio n a l d is c rim in a tio n

So,
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can be seen from the diagram that institutional racism is just one element of an overall life experience of oppression in society. Racism as a form of oppression has to be tackled at all of the levels that it operates individuals, groups, organisations, communities and in society at large. However, institutional racism is a very complex problem to address and this is reflected in the following definition: Institutional racism is the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance or thoughtlessness and racist stereotyping which disadvantages minority ethnic people. Sir William Macpherson, Chair of the Stephen Lawrence Inquiry (1999) To be effective, efforts to tackle racism at each level have to be coordinated and should be part of wider strategy to promote equality in a service organisation and the community it serves.

Activity 5.3 Key words in RECC

Look at the following definitions of some key words that are commonly used in RECC approaches many of which have already appeared in this module. Can you guess the word or phrase that is being defined? Key Words in RECC 1. Shared behaviours, traditions, values and norms amongst a group of people characterised by shared language, food, dress, symbols, myths, art and history. You have a degree of choice as to whether you take it on or not. A group of people who share traditions, heritage and history over a long period of time and come to identify closely with one another. It is often tied to a specific geographic location and usually involves shared language and religions. A political term of solidarity between people who are vulnerable to White racism as a result of their skin colour and physical appearance. Categorisation of people defined by colour of skin and physical appearance, which has developed from a falsely scientific way of thinking about human beings as arising from different species. It has now become a social concept with negligible importance attached to its biological and scientific connotations but is still influential in community relationships, the way we organise our institutions and power structures within society. Attitudes or beliefs that are negative towards certain groups of people and which are not founded on rational thinking or factual information. Commonly held assumptions and beliefs about particular racial and ethnic groups of people where everyone from that group is assumed to have specific personal characteristics because they belong to that group. In effect people are denied their individuality. Treating people differently which has come to mean unfair treatment of certain groups of people.

2.

3. 4.

5. 6.

7.

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8. The process of determining the nature and cause of illness, condition or injury through evaluation of patient history, examination, and review of clinical observations and evidence. Emphasising the importance of the whole and the inter-relationships between its parts. When applied to people it means a wide look at a persons situation including their social, political, economic and physical environment. A process where an individual regains control over their own lives and is enabled to make all the important decisions affecting her or him thereby increasing autonomy, helping the person to take responsibility and maintain their dignity and respect. A process whereby people are put under pressure to fit into the dominant culture in a society. An approach to tackling racism which is essentially educational in nature. It encourages people to learn about other peoples cultures and show equal respect for different cultures. This approach is a misguided attempt to treat everyone the same by ignoring a persons skin colour. The abusive use of power and/or authority to coerce, control, exclude or disadvantage groups or individuals in society resulting in social inequalities, discrimination and injustice. A special advantage or immunity or benefit not enjoyed by all inferring that some people have to bear a burden of not having such an advantage.

9.

10.

11. 12.

13. 14.

15. 16.

An approach to counteract racism in a whole systems way at individual, organisational and societal levels involving empowering individuals, challenging stereotypes and improving practices, policies and systems. Answers on the next page.

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The answers: Key Words in RECC 1. 2. 3. 4. 5. 6. 7. 8. Culture Ethnic Group Black Race Prejudice Stereotyping Discrimination Diagnosis 9. 10. 11. 12. 13. 14. 15. 16. Holistic Empowerment Assimilation Multicultural Colour-blind Oppression Privilege Race Equality

3. Key factors in BME mental health

The Government has acknowledged that racism and discrimination play a significant role in our mental health services. For example, Rosie Winterton, the Minister of State for Health said: There are significant and unacceptable inequalities in the access to mental health services that black and minority ethnic patients have, in their experience of those services and in the outcome of those services. Rates of compulsory admission are significantly higher for black and minority ethnic groups. Average lengths of stay in hospital are longer. BME patients are more likely than white people to be prescribed drugs or ECT rather than psychotherapy or counselling. All this fuels the circle of fear that can deter BME patients from seeking early treatment for their illness. (Jan 2005) The use of the term significant and unacceptable to describe the extent of the inequalities that BME service users face in our mental health services highlights the need for clearly defined actions to address such marked differences in experiences and outcomes. Poor outcomes are acknowledged to be systemic rather than due to individual differences between service users but this does not mean that we understand how they arise. Mental health service managers and practitioners are now being asked explicitly to look at what they can do differently to improve experiences and outcomes for BME service users and their families. This includes any ethnic group who may have different cultural norms and values from the majority culture and are vulnerable to discrimination, such as Travellers: Of the 200,000 to 300,000 Travellers in England, by far the largest group are Romany Gypsies, who have been in England since the early 16th century. Romany Gypsies have been recognised in law as a racial group since 1988 (see details of the 1989 test case CRE v Dutton ). Irish Travellers, who have been travelling in England as a distinct social group since the 1800s, received legal recognition as a racial group in England and Wales in 2000 (OLeary v Allied Domecq). (Commission for Racial Equality, 2006) We will outline the following six key factors in BME mental health that should be taken into consideration in an examination of any services:
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1. 2. 3. 4. 5. 6.

Compulsion -The increased likelihood of Black people coming into the psychiatric system through a compulsory route. Prevention - The lack of preventative and after-care mental health services which are appropriate for BME communities. Diagnosis - The increased incidence of diagnoses of serious mental health problems for Black people (particularly schizophrenia) Treatment - The over-use of drugs and physical treatments with BME service users rather than talking therapies Stereotyping - The increased likelihood of Black people being racially stereotyped by professionals in decisions about dangerousness Migration - The lack of response to refugees and asylum seekers.

Key factor 1: Compulsion - The increased likelihood of Black people coming into the
psychiatric system through a compulsory route

When I got caught by the police, the doctor told me that Im not allowed to stay in this country. He phoned the Home Office saying that I had committed a crime and that I was mentally ill. (African male service user, Ferns, 2003) Studies show that not only are African-Caribbean people over-represented within the mental health system but they are also more likely to be admitted under a compulsory order. Most studies suggest that this is particularly so for Black young men but there is evidence to suggest that the situation is just as bad if not worse for Black women. Furthermore, there is a strong perception among those working in Irish mental health that Irish men and women are also over-represented among those receiving ECT, being compulsorily detained and in secure units. Within psychiatric settings, black and minority patients are more likely than white people to be assessed as requiring greater degrees of supervision, control and security and, partly as a result, more likely than majority white people to be admitted to secure care environments. There is a very strong association between ethnicity and transfer/admission to secure units, particularly Medium Secure facilities. Over-representation of black people in high secure settings has also been an enduring feature of British psychiatric care. ..Evidence suggests that Irish people are also over-represented in all areas of the criminal justice system. (Inside Outside, Department of Health, 2003, page 14)

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Key factor 2: Prevention - The lack of preventative and after-care mental health services
which are appropriate for BME communities

I want more information Ive been in this country for 2 years and Ive just found out about Meals-on-Wheels. (BME service user, Ferns, 2003) The take-up of community mental health services by White people but not Black people is another theme running through the research. It is important to recognise, however, that when services are appropriate and available, there is evidence to suggest that Black people will use those services and benefit (Wilson & Francis,1997). Many individuals from minority ethnic groups encounter barriers when seeking help including language, the discrepancy between the patients and doctors views as to the nature of the presenting symptoms, cultural barriers to assessment produced by the reliance on a narrow biomedical approach, lack of knowledge about statutory services, and lack of access to bilingual health professionals. (Inside Outside, Department of Health, 2003)

Key factor 3: Diagnosis - The increased incidence of diagnoses of serious mental health
problems for Black people (particularly schizophrenia)

My diagnosis is not correct. My mental health problems are a side effect of spiritual transformation I take no tablets. (BME service user, Ferns, 2003) Over the last two decades, the main studies into mental health and race have consistently reported high rates of severe mental illness (particularly schizophrenia) among AfricanCaribbean people in comparison with rates among White people. It has been estimated that African Caribbean people are up to ten times more likely to receive a diagnosis of schizophrenia or psychosis. On the other hand, African Caribbean people, especially men, are under-represented in the diagnosis of neuroses such as depression and anxiety-related mental health problems. It has been noted that there is also an over-representation of Irish people in this area of severe mental illness. In contrast, however, people of Asian descent tend to be under-represented in the diagnosis of schizophrenia and over-represented in areas such as suicide and depression, particularly for Asian women.

Key factor 4: Treatment - The over-use of drugs and physical treatments with BME
service users rather than talking therapies

If I find that Karaoke helps me with my mental distress then it should be provided on the NHS. It would probably be cheaper than drugs. (BME service user, Ferns, 2003) Research evidence has suggested that both Asian and African-Caribbean people are more likely to receive physical treatments such as drugs and ECT rather than therapeutic talking services. This mostly arose from professionals viewing Black patients being more dangerous or presenting greater risks.
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Key factor 5: Stereotyping - The increased likelihood of Black people being racially
stereotyped by professionals in decisions about dangerousness

Cultural and racial stereotyping is a common experience in the context of assessment and decisions concerning treatment. This may well influence the types of services and diagnosis individuals from minority backgrounds seek and receive. There is evidence that stereotyping of Irish people as alcoholics obstructs treatment for mental health problems. Interpreting services are often unavailable, which makes the diagnosis or assessment procedure both unreliable and highly stressful. (Inside Outside, Department of Health, page 12) Some evidence also suggests that psychiatrists and others are more likely to consider African-Caribbean men as potentially dangerous compared to others. It is therefore possible that this group is more likely to be diagnosed with psychosis because of bias among those who treat them (Nazroo & King, 2002).

Key factor 6: Migration - The lack of response to refugees and asylum seekers
The Asylum Team have put me into a small room, miles from my daughter and grandchildren. I have no privacy, no TV and Im very distressed. (Woman Refugee, Ferns, 2003) Refugees and asylum seekers face many barriers in accessing health services including mental health services. They often have needs due to experiences of trauma from war such as imprisonment, torture and oppression. Coming to a new country without any family or social networks leads to further isolation especially if there is hostility and racism to contend with. Refugee women are subject to a range of physical and mental health problems, including gender-related difficulties, domestic and sexual violence, and sexual and reproductive health problems. The psychological stress they suffer is further compounded when they are separated from their children or faced with the loss of family members. As a consequence, anxiety, depression and post-traumatic stress disorder are commonly occurring among refugee women, along with widespread mental health problems. Attention also needs to be given to the activities of organised criminal gangs in the trafficking of women and children for sexual exploitation (prostitution) and forced labour. (Demir 2003).

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Activity 5.4. Key Factors in BME Mental Health: Dangers for BME service users
Look at the following grid with the six key factors and write down what you think are the main dangers for BME service users and the main challenges for mental health services in the right-hand columns. Key Factors 1. Compulsion Dangers for BME for service users Challenges for MH Services

2. Prevention

3. Diagnosis

4. Treatment

5. Stereotyping

6. Migration

Once you have completed the grid look at our grid on the following page. You may have some different points to make in relation to your local practice but compare your answers to some of the points we have made. We have also mapped two important ESCs to each key factor. Our grid Key Factors 1. Compulsion Dangers for BME service users BME people feel forced to use MH services are likely to experience services are controlling rather than genuinely helping them. In this situation of control people may become resentful and suspicious of services eventually avoiding them altogether. Challenges for MH services How to offer services to BME service users in a way that they find acceptable?

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2. Prevention Lack of access to preventative services means that people are more likely to enter MH services in crisis and more damage is done to BME individuals, families and communities. If BME people are not properly supported after a crisis it is likely that they will quickly re-enter acute services becoming revolving door patients. BME people are more likely to be misdiagnosed and stereotyped rather than having their real mental health needs assessed accurately. BME people are more likely to be offered inappropriate treatment with poorer outcomes thereby reinforcing the negative view of mental health services in BME communities. BME people will feel that mental health services are not in touch with the reality of their lives or interested in them as unique individuals and they will feel depersonalised and disempowered. Negative assumptions about people will lead to poor predictive assessments in risk management, labelling and increased feelings of social control. If the mental health needs of refugees and asylum seekers are not properly assessed and assistance offered there will be damaging social consequences not only for the individuals and families concerned but also the communities they live in. Issues such as mental distress, family breakdown, drug and alcohol abuse, domestic violence and criminality will become major challenges in these communities. How to reach out to BME people in mental distress who may need assistance before they go into a crisis? How to reduce stigma about mental health in BME communities? How to assess BME service users needs in a culturally appropriate and holistic way? How to create culturally appropriate alternatives to drugs and ECT for BME service users?

3. Diagnosis

4. Treatment

5. Stereotyping

How to ensure antidiscriminatory risk assessment and management in work with BME people?

6. Migration

How to provide early detection and effective intervention with respect to mental health needs of refugees and asylum seekers?

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Which of the Essential Shared Capabilities would be most effective dealing with the dangers for BME service users? Now we will link each of the key factors with two of the main ESCs. Key Factors 1. Compulsion Analysis of dangers for BME service users People often enter into the mental health system compulsorily in a crisis due to a breakdown in the persons support networks or lack of assistance. Strengthening the persons family, carer and other support networks is crucial. Compulsion involves the use of mental health legislation and attention to the persons rights in the situation is necessary. Greater efforts have to be made to prevent BME people from entering acute services, which means that work has to be done with people in their communities to develop valued and fulfilling roles. On discharge from hospital BME people will need help in overcoming any discriminatory barriers and stigma they may face in their communities. A narrow approach to diagnosis and assessment of mental health needs has proved to be damaging to BME people and information has to be collected in a holistic way. The cultural meanings of mental distress must be identified and respected in order to understand the needs of BME people properly. Goals for intervention with BME people and their families must address their concerns and be meaningful to them. Service users should be given access to culturally appropriate services that are designed around the specific needs of the person. Practitioners have to actively challenge stereotypes that BME service users may be vulnerable to. In risk work, BME service users should be enabled to make decisions about risks in their lives and practitioners should demonstrate their concern for the safety and well being of service users. Essential Shared Capabilities ESC 1 - Working in partnership ESC 3 - Practising Ethically

2. Prevention

ESC 4 - Challenging Inequality ESC 5 - Promoting Recovery

3. Diagnosis

ESC 2 - Respecting Diversity ESC 6 - Identifiying Peoples Needs & Strengths

4. Treatment

ESC 7 - Providing Service User Centred Care ESC 8 - Making a Difference

5. Stereotyping

ESC 4 - Challenging Inequality ESC 9 - Promoting Safety & Positive Risk Taking

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6. Migration Given the extremely poor access to mental health services, there is an urgent need for practitioners to work closely with refugee and asylum seeker groups to improve access. Constructive partnerships need to be built between newly arrived groups and local communities and mental health services have an important role to play in this task. This area of mental health work is involves rapidly changing practice due to conflicts and worldwide economic factors which will require practitioners to keep abreast of research and new mental health approaches in migration. ESC 1 - Working in Partnership ESC 10 - Personal Development & Learning

If you are in clinical work - think of a real BME service user you have worked with or know about and answer the following six questions which correspond to the six key factors. Once you have answered the questions about the person tick one or two of the most important key factors for that person on the grid. Key Factors 1. Compulsion How did the service user enter into mental health services? 2. Prevention What kind of help in the community may have prevented the person from entering acute mental health services? 3. Diagnosis Does the person agree with their diagnosis and how does s/he describe their mental distress? 4. Treatment What kind of treatments has the person been offered and used mainly? 5. Stereotyping Do you feel that the person has been subjected to any stereotypes? If so what? A BME service user tick

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6. Migration Has the person or their family been affected by the experience of migration? If so how? What could have been done differently to improve the experience of that person in mental health services?

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4. Breaking the circles of fear
There are many reasons for the over-representation of BME people in mental health services and their experience of different standards and outcomes in service delivery. Social and political factors play their part as do issues concerning power, economic disadvantage and social exclusion. The degree of the problem facing mental health services is characterised by a recent study about the experience of African-Caribbean people by the Sainsbury Centre for Mental Health (SCMH 2002, Breaking the Circles of Fear). What the SCMH has termed circles of fear have been created so that: many people, particularly in the Black African and Caribbean communities, do not believe that mainstream mental health services can offer positive help, so they delay seeking help; they therefore are not engaging with services at an early point in the cycle when they could receive less coercive and more appropriate services, coming instead to services in crisis when they face a range of risks including over and misdiagnosis, police intervention and use of the Mental Health Act; these aversive care pathways further influence both the nature and outcome of treatment and the willingness of communities to engage with mainstream services. (Delivering Race Equality:A Framework for Action, DoH, October 2003, page 8) We must all try to break these circles of fear if we are to ensure that BME people in mental distress get a fair deal from mental health services.

The three key themes that emerged from the Circles of Fear (SCMH 2002) research were: There are circles of fear that stop Black people from engaging with services Mainstream services are experienced as inhuman, unhelpful and inappropriate Problematic care pathways of Black people influence the type and outcome of treatment and the willingness of these communities to engage with mainstream services

As mental health practitioners, we need to think about our assumptions about people we consider to be different because of their racial or cultural backgrounds. This includes the way we understand what is meant by race and culture. We need to be aware of how these understandings can lead us to have negative views of some people we come into contact with. We also need to understand how these views influence the way we deal with a diverse range of people. Being aware of these things helps us to understand, respect and deal with service users, their families and carers in a fair manner.

Activity 5.5.
Consider how fear may influence decisions relating to the following procedures: Risk assessment (relates to ESC 9)

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Use of medication Control and restraint Referrals to seclusion, psychiatric intensive care, or Special Hospitals

(for further reading see: Keating, Frank and Robertson, David (2004) Fear, black people and mental illness: a vicious circle? Health and Social Care in the Community; 12 (5): 439-447)

Activity 5.6.
Read through the following and consider which of the ESCs these statements relate to:

African Caribbean service users and carers repeatedly ask to be treated with respect and dignity. They demand better information about services with less coercion, less reliance upon medication and other physical treatments and more choice. In this they concur with the views of many other service users and carers who have commented on their experience of mental health services. They wish to be treated and respected as individuals. From Breaking the Circles of Fear, Sainsbury Centre for Mental Health, 2002
African Caribbean service users and carers repeatedly ask to be treated with respect and dignity relates to ESC number/s:

They demand better information about services with less coercion, less reliance upon medication and other physical treatments and more choice. relates to ESC number/s:

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5. Delivering Race Equality
Inside Outside (Department of Health 2003)signalled reform of mental health care for BME communities. It was prepared by some of the leading people in the field and was supported by widespread public consultation. It identified three key objectives: to reduce and eliminate ethnic inequalities in mental health service experience and outcome; to develop the cultural capability of mental health services; and to engage the community and build capacity through community development workers. Delivering Race Equality (Department of Health 2003) proposed key strategic, whole system responses to Inside Outside to implement the reform it signalled. It described three main building blocks, closely related to the objectives of Inside Outside, which now form the foundations of an action plan: the development of appropriate, sensitive and responsive services; the engagement of BME communities with service providers; and good quality, intelligently used information on the ethnic profile of local populations and of service users.

The Governments Five Year Plan for achieving race equality and tackling discrimination in mental health services in England is the most important policy statement on BME mental health. It aims to achieve: Less fear of mental health services among BME communities and service users Increased satisfaction with services A reduction in the rate of admission of people from BME communities to psychiatric inpatient units A reduction in the disproportionate rates of compulsory detention of BME service users in inpatient units Fewer violent incidents that are secondary to inadequate treatment of mental illness A reduction in the use of seclusion in BME groups The prevention of deaths in mental health services following physical intervention More BME service users reaching self-reported states of recovery; A reduction in the ethnic disparities found in prison populations; A more balanced range of effective therapies, such as peer support services and psychotherapeutic and counselling treatments, as well as pharmacological interventions that are culturally appropriate and effective; A more active role for BME communities and BME service users in the training of professionals, in the development of mental health policy, and in the planning and provision of services A workforce and organisation capable of delivering appropriate and responsive mental health services to BME communities.

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Activity 5.7. Becoming an ally to BME service users
The list of DRE aims provides a useful framework to judge how well services are doing in relation to BME people. Practitioners who increase their knowledge of these indicators for BME mental health can become powerful allies for BME service users in their area and act to safeguard the rights of local BME people in the mental health system. Knowledge really is power and the checklist below is a reminder of some key questions that practitioners should be addressing if they wish to gain some power in challenging institutional racism in their area. Answer as many of the following questions as you can and work out how you will get the information required to answer all of them. Supporting Delivering Race Equality 1. 2. What do BME service users think about your service? What is the rate of admission of BME people to your local psychiatric in-patient units? What are the rates of compulsory detention of BME service users in your local inpatient units? What is the number of recorded violent incidents involving BME people in mental health facilities in your area? How often is seclusion used with BME service users within in-patient facilities? What is the number of deaths in mental health services following physical intervention over the past ten years? What are the views of BME service users about their recovery from mental distress and how services have helped them? What is the ethnic breakdown of the most local prison in your area? What culturally appropriate and alternative therapy services are there in your area, including talking therapies, which are available and accessible to BME people? How often and in what ways are BME service users and carers involved in the training of mental health practitioners in your area? Where will you get this information?

3.

4.

5. 6.

7.

8. 9.

10.

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11. What training and development opportunities are there for practitioners in relation to Race Equality and Cultural Capability?

How can you most effectively use your newly-found knowledge of BME mental health issues to bring about change in your service? This module will provide you with a good understanding of some fundamental issues and prepare you for the Race Equality and Cultural Capability foundation training materials which extend and examine in greater depth many of the issues covered in this ESC module.

5. Links to further learning References

Commission for Racial Equality (2006), Common Ground: Equality, good race relations and sites for Gypsies and Irish Travellers - Report of a CRE inquiry in England and Wales, London, Commission for Racial Equality. Demir J., (2003) quoted in Keating F, Robertson D & Kotecha N (2003) Ethnic Diversity and Mental Health in London - Recent developments. Kings Fund. Department of Health (2003) Delivering Race Equality: A Framework for Action. Mental Health Services consultation document, London, Department of Health. Department of Health (2005) Delivering race equality in mental health care: An action plan for reform inside and outside services and the Governments response to the Independent inquiry into the death of David Bennett, London: Department of Health.

Note: David Bennett was a 38-year-old African-Caribbean patient who died on 30 October
1998 in a medium secure psychiatric unit after being restrained by staff. The report of the independent inquiry into the death of David Bennett made important recommendations about the way that mental health care is delivered to service users, especially those from BME communities. The recommendations also address wider issues such as the safe use of physical intervention in mental health settings. The report of the independent inquiry into his death was published on 12 February 2004. Department of Health, June 2003, Caring for Dispersed Asylum Seekers: A Resource Pack London, Department of Health. Department of Health (2003) Inside Outside: Imposing Mental Health Services for Black and Minority Ethnic communities in England, London, Department of Health. Ferns P. (2003) Letting Through Light A service user-led Audit in Ealing, published by LitTle Project. West London Mental Health NHS Trust and Ealing Social Services Ferns P. (2000) in Race & Mental Health, in Bailey D. (ed), At the Core of Mental Health, Brighton, Pavilion
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Keating, Robertson & Kotecha (2003), Ethnic Diversity and Mental Health in London Recent developments, Kings Fund Macpherson, W. (1999) The Stephen Lawrence Inquiry: Report of an Inquiry by Sir William Macpherson of Cluny advised by Tom Cook, The Right Reverend Dr John Sentamu, Dr Richard Stone. London, The Stationery Office Nazroo J. & King M. (2002) Psychosis symptoms and estimated rates. In K Sproston and J. Nazroo (Ed.) Ethnic Minority Psychiatric Illness Rates in the Community (Empiric). National Centre for Social Research, TSO Sainsbury Centre for Mental Health (2002) Breaking the circles of fear. a review of the relationship between mental health services and African and Caribbean communities. London: Sainsbury Centre for Mental Health Wilson M. and Francis J. (1997), Raised Voices: African Caribbean and African Users Views and Experiences of Mental Health Services in England and Wales, MIND N.B. To follow from this module NIMHE/CSIP and CCAWI will be publishing substantial learning materials on Race Equality and Cultural Capability in 2007.

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