ESC Module 5

7/27/2019 ESC Module 5

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Page

The Ten Essential Shared Capabilities

Module5:

Raceequalityandculturalcapability

Author:PeterFernsOriginalAuthors:ErrolFranciswithIanGittens

Itisestimatedthatthereareover6millionpeopleinEnglandwhoaredesignatedas

fromblackandminorityethnicgroups.Black,Irishandotherminorityethnicgroups

experiencehighlevelsofsocialandmaterialdeprivationwhencomparedwiththe

majoritywhitepopulation.

(InsideOutside,2003,DepartmentofHealth,page9)

WelcometoModule5.ItisdesignedtohelpyouexplorethelinksbetweentheTen

EssentialSharedCapabilitiesandraceequalityandculturalcapability.

KeyESCElements:RespectingDiversity,ChallengingInequality,ProvidingServiceUser

CentredCare,MakingaDifference.

Aftercompletingthismoduleyouwill:

BeawareofthehistoryandbackgroundtotheexperienceofBlackandMinority

Ethnic(BME)mentalhealthserviceusers

Understandtheconnectionsbetweenthebroadthemesrelatingtorace,culture,

oppression,mentalhealth,theTenEssentialSharedCapabilitiesandyour

personalpractice

Understandandbeabletoapplyanumberofkeytermsandconceptswithinthe

race,cultureandmentalhealthdebate

Understandtheimportanceoforganisationalaswellasindividualchangein

relationtodeliveringraceequality

Contents

.ApproachestoRaceEqualityandCulturalCapability(RECC)...................2

2. Dening some fundamental ideas in RECC................................................ 7

3.KeyfactorsinBlackandMinorityEthnic(BME)mentalhealth..................

4.BreakingtheCirclesofFear.......................................................................20

5.DeliveringRaceEquality.......................................................22

6.Linkstofurtherlearning...............................................................................24


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Page2Module5:RaceEqualityandCulturalCapability

.ApproachestoRaceEquality&CulturalCapability

The rst step towards achieving race equality is to become more aware of problems that

existforBMEpeopleinyourservice.Ifyoudonotrecogniseaproblemitwillneverget

addressed. Awareness depends on how reective practitioners are and how well a critical

analysisofserviceprovisionisconducted.

Activity5.

Lookingatwhereindividualsarecomingfrom

Howwouldyouanalysethesecommonstatements?

Writeyourresponsesintheright-handcolumn.

.WedonthaveanyBlack

peoplearoundheresoitsnot

aproblem.

.

2. BME people should t into

ourcultureandthentheywould

have fewer difculties with

services.

2.

3.Wejustneedtolearnmore

aboutandrespectother

peoplesculturesandwewill

thentackleracismeffectively.

3.

4.Itdoesntmattertomewhat

colourpeopleareItreat

everybodythesame.

4.

5.IfyougetmoreBMEworkers

intheservicewewillbeableto

meettheneedsofBMEservice

users.

5.

6.Institutionalracismissucha

bigproblemthereisverylittle

thatIcandoaboutit.

6.

7. We just dont have enough

resourcestoprovideaspecialistservicetoBME

people.

7.

Ifyouaredoingthisactivityinagroupdiscussyouranswerswithtwootherpeople.Compare

whatyouhavewrittenwithourgridonthefollowingpage.



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Ourgrid

.Wedonthaveany

Blackpeoplearoundhere

soitsnotaproblem.

Thisstatementmakesanassumptionthatracismexistsonly

ifBlackpeoplearepresentthisisnottrue.Itcouldbethat

racismisabiggerproblemwherethereareonlyaveryfewBMEpeople.Racism,aswithotherformsofdiscrimination,

merelythrowsaspotlightontogeneralproblemsand

weaknesseswithinaservicesoraceequalityisaboutgood

practiceforallserviceusers.

2.BMEpeopleshould

t into our culture and

theywouldhavefewer

difculties with services.

This statement begs the question about who denes our

culture and whether it can be dened in such a way. All

culturesarecomplexandcomprisedofmanydifferentcultural

inuences, there has always been mixing and combining of

culturesthroughouttheages.Furthermore,mostBlackpeople

havebeenbornhereandarefullypartofBritishculturebut

stillexperiencediscriminationonthebasisofskincolourand

appearance.Furthermore,theapproachheredisplaysa

degreeofculturalarroganceinassumingthatthedominant

culturehasnothingtolearnfromotherculturesandsothisis

anassimilationapproach.

3.Wejustneedtolearn

moreaboutandrespect

otherpeoplescultures

andwewillthentackle

racismeffectively.

Thisstatementisessentiallyamulticulturalapproach.It

assumesthateducationandarationalapproachwillbe

sufcient in tackling racism but many aspects of prejudice

anddiscriminationarenotrational.Italsoassumesthat

knowledgegainedbytheindividualwillbeusedtoreduce

discriminationjustknowingaboutcultureisnotenoughtotackleracism.Knowledgeaboutthevarietiesofwaysinwhich

racismismanifestedcouldhelpbutknowledgealonedoes

notnecessarilychangebehaviourorimpactondiscrimination,

powerandstructuralinequalitiesinsocietymustalsobetaken

intoaccount.

4.Itdoesntmattertome

whatcolourpeopleare

Itreateverybodythe

same.

Thisapproachiscolour-blindandassumesthatequalityis

abouttreatingeverybodythesamebutwearealldifferent

withdifferentneeds.Equalityisaboutequalrespectbutnot

necessarilythesametreatment.Apersonsskincolourmay

wellbeanimportantaspectofthatpersonsidentityandlife

experience and denial of its signicance devalues the persons

viewoftheirrealityinsociety.

5.IfyougetmoreBME

workersintheservicewe

willbeabletomeetthe

needsofBMEservice

users.

ThestatementdisplaysanassumptionthatanyBMEworkers

willbeabletomeettheneedsofBMEserviceusersmerely

becauseoftheirraceorethnicitythisistoosimplistic.The

needsofBMEserviceusersmaynotbemetbyBMEworkersif

theydonothavethenecessaryknowledgeorskills.



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6.Institutionalracismis

suchabigproblemthere

isverylittlethatIcando

aboutit.

Thisstatementsuggeststhatindividualpractitionersare

powerlessandcandolittletochallengeinstitutionalracism.

Raceequalitystartswiththeindividualcommitmentof

practitionersandwiththemtakingaccountabilityfortheirown

practice.TheexperiencesofservicequalityofBMEserviceusersareoftendeterminedbythepracticeoftheindividual

practitionersdealingwiththem.

7. We just dont have

enoughresourcesto

provideaspecialist

servicetoBMEpeople.

ThestatementexcludesBMEserviceusersfromthe

mainstreamofmentalhealthservices,marginalisesthem

anddeniespeopleafairshareofresources.BMEpeopleare

taxpayersandcontributorstosocietyasmuchasanyother

groupofcitizens.ThereisalsoasuggestionherethatBME

peopleareextremelydifferentintheirbasicneedscomparedto

otherserviceuserswhichisnottrue.

Nowanswerthefollowingquestions:

WhatkindofthingshaveyousaidaboutRECCissuesinthepast?

Doyoustillbelieveinwhatyousaid?

Ifyouhavealteredyourviewswhathelpedyoutoshiftyourthinking?

Activity5.2

Lookingatwhereyourserviceiscomingfrom?

Lookatthefollowingstatementsandputatickagainsttheone(s)youfeelmostrepresent

yourservicesapproachtoissuesofRaceEqualityandCulturalCapability.

.Institutionalracismisnotseenasseriousorwidespreadasthe

Governmentmakesoutanditseemsthatmostpeopleintheorganisation

feelthattoobigafussismadeaboutit.

2.Peopleacceptthatinstitutionalracismexistsinmanymentalhealth

servicesbutmostpeoplesaythattheyhavenotreallycomeacrossitatall

intheirservices.

3.Peopleknowinstitutionalracismisawidespreadprobleminmental

healthservicesbutitisfeltthatservicesaredoingthebesttheycangiven

theresources.



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4.Itisgenerallyfeltthatinstitutionalracismisaproblemineverymental

healthservicebutmostpeoplefeelthattheyhaveaddresseditintheir

serviceandsoitsnotabigproblemanymore.

5. People feel that it is ne to look at BME issues in mental health but itisfeltthatsomeperspectivehasbeenlostasthereareotherissuesof

equalitywhicharethoughttobeevenmoreimportant,suchasgender

issuesorpoverty.

6.Peoplecanseethatinstitutionalracismisabigprobleminmentalhealth

servicesandthattheyneedtoimprovethingsbuttheycannotseehow

they can directly inuence change.

7. The service has found out about BME peoples experiences of services

andhastalkedtoserviceusersandfamiliesdirectly.Institutionalracismis

alsodiscussedamongstcolleaguesbutitisfelttobesuchabigproblem

thatpeopledontknowwheretostart.

8. Most people have been careful to reect on their practice and look out

forinstancesofracialdiscriminationinservices.Peoplehaverecorded

things,gatheredevidenceofproblemsandfeditthroughtomanagement

butnothingseemstohavecomeofit.

9.Someteamshaveformulatedactionplanstopromoteraceequality

andtheyhavesettaskstotackleproblemsandgapsforBMEpeoplein

theservice.Theyfeelthatoncetheyachievetheirgoalstheywillhave

improvedtheservice.

0.TeamactionplanstoimproveservicesforBMEpeoplearepartof

awiderRaceEqualitystrategythateveryonehascontributedtointhe

organisation.Thereareregularreviewsandmonitoringaboutwhatisbeing

doneintheorganisationtoachievecontinualimprovementsoverthelong

haul.

Once you have nished ticking the statement(s) to record where your service is, read about

theRaceEqualityScaleonthenextpage.



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TheRaceEqualityScale

Hostility Sometimespeoplemaybehostileduetoangeratbeing

accusedofbeingracistasitisperceivedbythem.More

often,itsuggestsafailuretorecogniseinstitutionalracismasaproblematall.Trainerswhotrytohighlightinstitutionalracism

arepresumedtohaveahiddenpoliticalagendaandWhite

trainerswhodothisaresomehowbetrayingtheirownpeople.

2 Denial Thisresponsemayrecognisethatinstitutionalracismexists

elsewherebutnothere.Peoplewillclaimthatthereareno

problemswiththeirservicesinrelationtoBMEpeopleeven

whenpresentedwithevidencetothecontrary.Ifpeoplein

denialarepressedhardertheymayenterintoahostile

responseinstead.

3 Apathy Thisresponseessentiallydoesnotviewinstitutionalracismas

beingallthatbadanddiscriminationisseenasunavoidable.

Individualswhoexperienceracismareexpectedtoaccept

itandmakethebestoftheirsituation.Servicechangeis

seenasbeingtoohardorunrealistic.Apathyisarguably

themosteffectivedriverofinstitutionalracismaspeoplewith

power and inuence in services need only be apathetic and

notquestiondiscriminatorysystems,policies,proceduresand

organisationalculturesforinstitutionalracismtothrive.Inother

words,practitionersdonothavetobeactivelyracisttoracially

discriminatetheyjusthavetobeapatheticandthesystem

discriminates.4 Pretence Inthisresponsepeoplerecognisethereisaproblemwith

racismbutdealwithcriticismbyclaimingthatproblemshave

beenaddressedwhentheyhavenot.Peoplemayexaggerate

smallstepstowardsprogressortakecreditforafewexcellent

agenciesintheirareawhilstnottacklingseriousproblems

withinthemajorityoflocalservices.Theneteffectofthis

responseistoincreasethehiddennatureofinstitutionalracism

leadingtotokenismandthecreationoffurtherbarriersto

progress.

5 Avoidance Peopleengaginginthisresponserecognisethatinstitutional

racism is a problem in services but they will deect criticism

aboutracismbyclaimingthatotherformsofdiscrimination

areworsesuchassexismordiscriminationagainstdisabled

people.Ahierarchyofoppressionisconstructedinpeoples

mindswhichisbothdivisiveanddoesnotleadtoacoherent

value-baseforequalityasawhole.

6 Puzzlement Anotherresponsefollowingrecognitionoftheproblemofracism

couldbeoneofpuzzlementatwhattodoaboutit.People

may express feelings of being deskilled and uncondent

aboutdealingwithBMEpeople.Theremaywellbeadesireto

improvepracticebutlackofclarityabouthowtodothis.



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Page 7Module5:RaceEqualityandCulturalCapability

7 Acknowledge-

ment

ThisresponsedemonstratesadegreeofempathyforBME

peopleonthereceivingendofdiscrimination.Itactively

communicates awareness of institutional racism and afrms the

experiencesofBMEpeople.However,acknowledgementdoes

notnecessarilyleadtoactualimprovements.

8 Analysis Practitionersactivelymonitorfordiscrimination,record

experiencesofBMEpeopleandgatherevidencetoanalyse

thepatternsofdiscriminationoccurringinservices.However,

analysisdoesnotguaranteethatchangeswillhappen.

9 Action Inthisresponsepractitionersandmanagersactontheir

analysis,formulateactionplanstoaddressproblemsandgaps

inservicesforBMEpeopleandcarryouttheirplantoachieve

thetargets/goalsset.

0 SustainedImprovement

Hereactionplansarecoordinatedthroughawiderraceequalitystrategyacrossthewholeorganisationandlocal

communityandtheyareregularlymonitored.Aseriesofaction

plansarecarriedoutoveraperiodoftimetoachieveongoing

improvements.

TickwhereyourService/Teamisasawholeonthisscale.

2 3 4 5 6 7 8 9 0

Nowanswerthefollowingquestion:

WhatwouldyourService/Teamhavetodotoimproveitspositionontheraceequality

scalebyatleastonestep?

Ifyouaredoingthisactivityinagroupcompareyourratingswithyourcolleagues.Discuss

anydifferencesinyourratingsandwhatyourevidenceisforyourjudgements.

2. Dening 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)

Theconceptofcultureisveryimportantbutitisalsoquitecomplex.Herewewilllookat

howcultureandpowercancombinetocreateoppressionanddiscrimination(seediagram



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below).Ineverysocietypeoplearebornwithoracquiredifferencesintheirlivesandtheway

power is used in that society inuences the meanings given to differences. So, people can

bebornwithdifferencessuchasaparticularappearance,skincolourorphysicalimpairment

butmayacquiredifferencesinbeliefsorvaluesthroughtheirculturalcontextortheymay

acquireaphysicaldisabilitythroughillnessoraccident.Thebeliefsandassumptionscanbepositiveornegativeandquiteoftenpeopledonotrequireanyevidencetoholdthemthese

are prejudices that inuence the values assigned to individuals and the social groups they

belongto.

Oncedifferentvaluesareassignedregularlytocertainsocialgroupsovertimetheybegin

togeneratepositiveornegativestereotypesaboutthesegroups.Forinstance,peoplewho

attenduniversityatOxfordorCambridgemayhaveapositiveassumptionmadeaboutthem

thattheywillbegoodleadersorpeoplewhoarehomelessmayhaveanegativeassumption

madeaboutthemthattheyhavebroughttheirsituationuponthemselves.Thepower

structureswithinsocietywhichhelpcreateprejudicesandstereotypesthenincorporate

themintothestructuresandsystemsoforganisationsandservicesthataffectpeopleslifeopportunities;suchaseducation,health,employmentandmentalhealth.Theprocess

leadstoeasyaccessforthosepositivelystereotypedandunfairbarriersforthosenegatively

stereotyped.Ultimatelysomesocialgroupsenjoyprivilegewhilstothersaresubjectedto

oppressionneitheroutcomeisdesirableastheyarebothbasedonunfairnessandsocial

injustice.

Racismasaformofoppressionthenoperatesatanindividuallevelwithprejudicesand

stereotyping inuencing relationships and communication between practitioners and

service users. Racism at an organisational level inuences services through stereotypes

andreinforcesthemthroughpolicies,proceduresandsystemscontributingtoinstitutional

discrimination.Racismatthesocietallevelcreatesdiscriminatorypowerstructures

andmaintainsstereotypes;itsupportsdiscriminatoryorganisationsthroughpoorpolicy

implementationandfurtherstrengthensinstitutionaldiscrimination.

So, it

People born wi th or ac u ire

Posit ive

ValuesNegativeValues

Easy

accessUnfair

barr iers

Unfair

advantages

Prejudices

Stereotypes

Insti tut ionaldiscrimination

Posit ive

Beliefs

Negative

Beliefs

People born wi th or ac u ire

Posit ive

ValuesNegativeValues

Easy

accessUnfair

barr iers

Unfair

advantages

Prejudices

Stereotypes

Insti tut ionaldiscrimination

Posit ive

Beliefs

Negative

Beliefs



9/26


canbeseenfromthediagramthatinstitutionalracismisjustoneelementofanoveralllife

experienceofoppressioninsociety.Racismasaformofoppressionhastobetackledatall

ofthelevelsthatitoperatesindividuals,groups,organisations,communitiesandinsociety

atlarge.However,institutionalracismisaverycomplexproblemtoaddressandthisis

reected in the following denition:

Institutionalracismisthecollectivefailureofanorganisationtoprovideanappropriate

andprofessionalservicetopeoplebecauseoftheircolour,cultureorethnicorigin.Itcan

beseenordetectedinprocesses,attitudesandbehaviourwhichamounttodiscrimination

throughunwittingprejudice,ignoranceorthoughtlessnessandraciststereotypingwhich

disadvantagesminorityethnicpeople.

SirWilliamMacpherson,ChairoftheStephenLawrenceInquiry(999)

Tobeeffective,effortstotackleracismateachlevelhavetobecoordinatedandshouldbe

partofwiderstrategytopromoteequalityinaserviceorganisationandthecommunityit

serves.

Activity5.3

KeywordsinRECCLook at the following denitions of some key words that are commonly used in RECC

approachesmanyofwhichhavealreadyappearedinthismodule.

Can you guess the word or phrase that is being dened?

KeyWordsinRECC. Sharedbehaviours,traditions,valuesandnormsamongstagroupofpeople

characterisedbysharedlanguage,food,dress,symbols,myths,artandhistory.

Youhaveadegreeofchoiceastowhetheryoutakeitonornot.

2. Agroupofpeoplewhosharetraditions,heritageandhistoryoveralongperiod

of time and come to identify closely with one another. It is often tied to a specic

geographiclocationandusuallyinvolvessharedlanguageandreligions.

3. ApoliticaltermofsolidaritybetweenpeoplewhoarevulnerabletoWhiteracismas

aresultoftheirskincolourandphysicalappearance.

4. Categorisation of people dened by colour of skin and physical appearance,

which has developed from a falsely scientic way of thinking about human beingsasarisingfromdifferentspecies.Ithasnowbecomeasocialconceptwith

negligible importance attached to its biological and scientic connotations but is

still inuential in community relationships, the way we organise our institutions and

powerstructureswithinsociety.

5. Attitudesorbeliefsthatarenegativetowardscertaingroupsofpeopleandwhich

arenotfoundedonrationalthinkingorfactualinformation.

6. Commonlyheldassumptionsandbeliefsaboutparticularracialandethnic

groups of people where everyone from that group is assumed to have specic

personalcharacteristicsbecausetheybelongtothatgroup.Ineffectpeopleare

deniedtheirindividuality.

7. Treatingpeopledifferentlywhichhascometomeanunfairtreatmentofcertain

groupsofpeople.



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11/26

PageModule5:RaceEqualityandCulturalCapability

Theanswers:

KeyWordsinRECC

. Culture 9. Holistic

2. EthnicGroup 0. Empowerment3. Black . Assimilation

4. Race 2. Multicultural

5. Prejudice 3. Colour-blind

6. Stereotyping 4. Oppression

7. Discrimination 5. Privilege

8. Diagnosis 6. RaceEquality

3.KeyfactorsinBMEmentalhealth

The Government has acknowledged that racism and discrimination play a signicant role in

ourmentalhealthservices.Forexample,RosieWinterton,theMinisterofStateforHealth

said:

There are signicant and unacceptable inequalities in the access to mental

healthservicesthatblackandminorityethnicpatientshave,intheirexperience

ofthoseservicesandintheoutcomeofthoseservices.Ratesofcompulsory

admission are signicantly higher for black and minority ethnic groups. Average

lengthsofstayinhospitalarelonger.BMEpatientsaremorelikelythanwhite

peopletobeprescribeddrugsorECTratherthanpsychotherapyorcounselling.

AllthisfuelsthecircleoffearthatcandeterBMEpatientsfromseekingearly

treatmentfortheirillness.(Jan2005)

The use of the term signicant and unacceptable to describe the extent of the

inequalitiesthatBMEserviceusersfaceinourmentalhealthserviceshighlightstheneedfor

clearly dened actions to address such marked differences in experiences and outcomes.

Pooroutcomesareacknowledgedtobesystemicratherthanduetoindividualdifferences

betweenserviceusersbutthisdoesnotmeanthatweunderstandhowtheyarise.Mental

healthservicemanagersandpractitionersarenowbeingaskedexplicitlytolookatwhatthey

candodifferentlytoimproveexperiencesandoutcomesforBMEserviceusersandtheir

families.Thisincludesanyethnicgroupwhomayhavedifferentculturalnormsandvaluesfromthemajoritycultureandarevulnerabletodiscrimination,suchasTravellers:

Ofthe200,000to300,000TravellersinEngland,byfarthelargestgroupareRomany

Gypsies,whohavebeeninEnglandsincetheearly6thcentury.RomanyGypsieshave

beenrecognisedinlawasaracialgroupsince988(seedetailsofthe989testcase

CREvDutton).IrishTravellers,whohavebeentravellinginEnglandasadistinctsocial

groupsincethe800s,receivedlegalrecognitionasaracialgroupinEnglandandWales

in2000(OLearyvAlliedDomecq).

(CommissionforRacialEquality,2006)

WewilloutlinethefollowingsixkeyfactorsinBMEmentalhealththatshouldbetakeninto

considerationinanexaminationofanyservices:



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Compulsion-TheincreasedlikelihoodofBlackpeoplecominginto

thepsychiatricsystemthroughacompulsoryroute.

Prevention-Thelackofpreventativeandafter-carementalhealthserviceswhichareappropriateforBMEcommunities.

Diagnosis-Theincreasedincidenceofdiagnosesofseriousmental

healthproblemsforBlackpeople(particularlyschizophrenia)

Treatment-Theover-useofdrugsandphysicaltreatmentswithBME

serviceusersratherthantalkingtherapies

Stereotyping-TheincreasedlikelihoodofBlackpeoplebeingracially

stereotypedbyprofessionalsindecisionsaboutdangerousness

Migration-Thelackofresponsetorefugeesandasylumseekers.

1.

2.

3.

4.

5.

6.

Key factor 1: Compulsion-TheincreasedlikelihoodofBlackpeoplecomingintothe

psychiatricsystemthroughacompulsoryroute

WhenIgotcaughtbythepolice,thedoctortoldmethatImnotallowedtostayinthis

country. He phoned the Home Ofce saying that I had committed a crime and that I was

mentallyill.

(Africanmaleserviceuser,Ferns,2003)

StudiesshowthatnotonlyareAfrican-Caribbeanpeopleover-representedwithinthemental

healthsystembuttheyarealsomorelikelytobeadmittedunderacompulsoryorder.Most

studiessuggestthatthisisparticularlysoforBlackyoungmenbutthereisevidencetosuggestthatthesituationisjustasbadifnotworseforBlackwomen.Furthermore,thereis

astrongperceptionamongthoseworkinginIrishmentalhealththatIrishmenandwomen

arealsoover-representedamongthosereceivingECT,beingcompulsorilydetainedandin

secureunits.

Withinpsychiatricsettings,blackandminoritypatientsaremorelikelythanwhitepeople

tobeassessedasrequiringgreaterdegreesofsupervision,controlandsecurityand,

partlyasaresult,morelikelythanmajoritywhitepeopletobeadmittedtosecurecare

environments.Thereisaverystrongassociationbetweenethnicityandtransfer/admission

tosecureunits,particularlyMediumSecurefacilities.Over-representationofblackpeople

inhighsecuresettingshasalsobeenanenduringfeatureofBritishpsychiatriccare.

..EvidencesuggeststhatIrishpeoplearealsoover-representedinallareasofthecriminal

justicesystem.

(InsideOutside,DepartmentofHealth,2003,page4)



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Key factor 2: Prevention-Thelackofpreventativeandafter-carementalhealthservices

whichareappropriateforBMEcommunities

IwantmoreinformationIvebeeninthiscountryfor2yearsandIvejustfoundoutabout

Meals-on-Wheels.(BMEserviceuser,Ferns,2003)

Thetake-upofcommunitymentalhealthservicesbyWhitepeoplebutnotBlackpeopleis

anotherthemerunningthroughtheresearch.Itisimportanttorecognise,however,thatwhen

servicesareappropriateandavailable,thereisevidencetosuggestthatBlackpeoplewill

use those services and benet (Wilson & Francis,1997).

Manyindividualsfromminorityethnicgroupsencounterbarrierswhenseekinghelp

includinglanguage,thediscrepancybetweenthepatientsanddoctorsviewsastothe

natureofthepresentingsymptoms,culturalbarrierstoassessmentproducedbythe

relianceonanarrowbiomedicalapproach,lackofknowledgeaboutstatutoryservices,and

lackofaccesstobilingualhealthprofessionals.

(InsideOutside,DepartmentofHealth,2003)

Key factor 3: Diagnosis-Theincreasedincidenceofdiagnosesofseriousmentalhealth

problemsforBlackpeople(particularlyschizophrenia)

Mydiagnosisisnotcorrect.Mymentalhealthproblemsareasideeffectofspiritual

transformationItakenotablets.

(BMEserviceuser,Ferns,2003)

Overthelasttwodecades,themainstudiesintomentalhealthandracehaveconsistently

reportedhighratesofseverementalillness(particularlyschizophrenia)amongAfrican-

CaribbeanpeopleincomparisonwithratesamongWhitepeople.Ithasbeenestimated

thatAfricanCaribbeanpeopleareuptotentimesmorelikelytoreceiveadiagnosisof

schizophreniaorpsychosis.Ontheotherhand,AfricanCaribbeanpeople,especiallymen,

areunder-representedinthediagnosisofneurosessuchasdepressionandanxiety-related

mentalhealthproblems.Ithasbeennotedthatthereisalsoanover-representationofIrish

peopleinthisareaofseverementalillness.Incontrast,however,peopleofAsiandescent

tendtobeunder-representedinthediagnosisofschizophreniaandover-representedin

areassuchassuicideanddepression,particularlyforAsianwomen.

Key factor 4: Treatment-Theover-useofdrugsandphysicaltreatmentswithBME

serviceusersratherthantalkingtherapies

If I nd that Karaoke helps me with my mental distress then it should be provided on the

NHS.Itwouldprobablybecheaperthandrugs.

(BMEserviceuser,Ferns,2003)

ResearchevidencehassuggestedthatbothAsianandAfrican-Caribbeanpeopleare

morelikelytoreceivephysicaltreatmentssuchasdrugsandECTratherthantherapeutic

talkingservices.ThismostlyarosefromprofessionalsviewingBlackpatientsbeingmoredangerousorpresentinggreaterrisks.



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Key factor 5: Stereotyping-TheincreasedlikelihoodofBlackpeoplebeingracially

stereotypedbyprofessionalsindecisionsaboutdangerousness

Culturalandracialstereotypingisacommonexperienceinthecontextofassessmentand decisions concerning treatment. This may well inuence the types of services and

diagnosisindividualsfromminoritybackgroundsseekandreceive.Thereisevidencethat

stereotypingofIrishpeopleasalcoholicsobstructstreatmentformentalhealthproblems.

Interpretingservicesareoftenunavailable,whichmakesthediagnosisorassessment

procedurebothunreliableandhighlystressful.

(InsideOutside,DepartmentofHealth,page2)

Someevidencealsosuggeststhatpsychiatristsandothersaremorelikelytoconsider

African-Caribbeanmenaspotentiallydangerouscomparedtoothers.Itisthereforepossible

thatthisgroupismorelikelytobediagnosedwithpsychosisbecauseofbiasamongthose

whotreatthem(Nazroo&King,2002).

Key factor 6: Migration-Thelackofresponsetorefugeesandasylumseekers

TheAsylumTeamhaveputmeintoasmallroom,milesfrommydaughterand

grandchildren.Ihavenoprivacy,noTVandImverydistressed.

(WomanRefugee,Ferns,2003)

Refugeesandasylumseekersfacemanybarriersinaccessinghealthservicesincluding

mentalhealthservices.Theyoftenhaveneedsduetoexperiencesoftraumafromwarsuchasimprisonment,tortureandoppression.Comingtoanewcountrywithoutanyfamilyor

socialnetworksleadstofurtherisolationespeciallyifthereishostilityandracismtocontend

with.

Refugeewomenaresubjecttoarangeofphysicalandmentalhealthproblems,including

gender-related difculties, domestic and sexual violence, and sexual and reproductive

healthproblems.Thepsychologicalstresstheysufferisfurthercompoundedwhentheyare

separatedfromtheirchildrenorfacedwiththelossoffamilymembers.Asaconsequence,

anxiety,depressionandpost-traumaticstressdisorderarecommonlyoccurringamong

refugeewomen,alongwithwidespreadmentalhealthproblems.Attentionalsoneedstobe

given to the activities of organised criminal gangs in the trafcking of women and children

forsexualexploitation(prostitution)andforcedlabour.(Demir2003).



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Activity5.4.KeyFactorsinBMEMentalHealth:DangersforBMEserviceusers

Lookatthefollowinggridwiththesixkeyfactorsandwritedownwhatyouthinkarethemain dangers for BME service usersandthemain challenges for mental health

services intheright-handcolumns.

Key Factors Dangers for BME for

service users

Challenges for MH

Services

.Compulsion

2.Prevention

3.Diagnosis

4.Treatment

5.Stereotyping

6.Migration

Onceyouhavecompletedthegridlookatourgridonthefollowingpage.Youmayhave

somedifferentpointstomakeinrelationtoyourlocalpracticebutcompareyouranswersto

someofthepointswehavemade.WehavealsomappedtwoimportantESCstoeachkey

factor.

OurgridKey Factors Dangers for BME service users Challenges for MH

services

1. Compulsion BMEpeoplefeelforcedtouseMH

servicesarelikelytoexperience

servicesarecontrollingratherthan

genuinelyhelpingthem.Inthis

situationofcontrolpeoplemay

becomeresentfulandsuspicious

ofserviceseventuallyavoiding

themaltogether.

How to offer services

to BME service users

in a way that they fnd

acceptable?



16/26


2. Prevention Lackofaccesstopreventative

servicesmeansthatpeopleare

morelikelytoenterMHservices

incrisisandmoredamageis

donetoBMEindividuals,familiesandcommunities.IfBMEpeople

arenotproperlysupportedafter

acrisisitislikelythattheywill

quicklyre-enteracuteservices

becomingrevolvingdoorpatients.

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?

3. Diagnosis BMEpeoplearemorelikelytobe

misdiagnosedandstereotyped

ratherthanhavingtheirrealmental

healthneedsassessedaccurately.

How to assess BME

service users needs in a

culturally appropriate and

holistic way?

4. Treatment BMEpeoplearemorelikelytobeofferedinappropriatetreatment

withpooreroutcomesthereby

reinforcingthenegativeviewof

mentalhealthservicesinBME

communities.

How to create culturallyappropriate alternatives

to drugs and ECT for BME

service users?

5. Stereotyping BMEpeoplewillfeelthat

mentalhealthservicesare

notintouchwiththereality

oftheirlivesorinterestedin

themasuniqueindividualsand

theywillfeeldepersonalisedanddisempowered.Negative

assumptionsaboutpeoplewilllead

topoorpredictiveassessmentsin

riskmanagement,labellingand

increasedfeelingsofsocialcontrol.

How to ensure anti-

discriminatory risk

assessment and

management in work with

BME people?

6. Migration Ifthementalhealthneedsof

refugeesandasylumseekers

arenotproperlyassessedand

assistanceofferedtherewillbe

damagingsocialconsequences

notonlyfortheindividualsand

familiesconcernedbutalsothe

communitiestheylivein.Issues

suchasmentaldistress,family

breakdown,drugandalcohol

abuse,domesticviolenceand

criminalitywillbecomemajor

challengesinthesecommunities.

How to provide early

detection and effective

intervention with respect

to mental health needs

of refugees and asylum

seekers?



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Page 17Module5:RaceEqualityandCulturalCapability

WhichoftheEssentialSharedCapabilitieswouldbemosteffectivedealingwiththedangers

forBMEserviceusers?NowwewilllinkeachofthekeyfactorswithtwoofthemainESCs.

Key Factors Analysis of dangers for BME service

users

Essential Shared

Capabilities1. Compulsion Peopleoftenenterintothemental

healthsystemcompulsorilyinacrisis

duetoabreakdowninthepersons

supportnetworksorlackofassistance.

Strengtheningthepersonsfamily,

carerandothersupportnetworksis

crucial.Compulsioninvolvestheuseof

mentalhealthlegislationandattention

tothepersonsrightsinthesituationis

necessary.

ESC 1 - Working in

partnership

ESC 3 - Practising

Ethically

2. Prevention Greatereffortshavetobemadeto

preventBMEpeoplefromentering

acuteservices,whichmeansthat

workhastobedonewithpeoplein

theircommunitiestodevelopvalued

and fullling roles. On discharge from

hospitalBMEpeoplewillneedhelpin

overcominganydiscriminatorybarriers

andstigmatheymayfaceintheir

communities.

ESC 4 - Challenging

Inequality

ESC 5 - Promoting

Recovery

3. Diagnosis Anarrowapproachtodiagnosisandassessmentofmentalhealthneedshas

provedtobedamagingtoBMEpeople

andinformationhastobecollectedin

aholisticway.Theculturalmeaningsof

mental distress must be identied and

respectedinordertounderstandthe

needsofBMEpeopleproperly.

ESC 2 - RespectingDiversity

ESC 6 - Identifying

Peoples Needs &

Strengths

4. Treatment GoalsforinterventionwithBMEpeople

andtheirfamiliesmustaddresstheir

concernsandbemeaningfultothem.

Serviceusersshouldbegivenaccess

toculturallyappropriateservicesthat

are designed around the specic needs

oftheperson.

ESC 7 - Providing Service

User Centred Care

ESC 8 - Making a

Difference

5. Stereotyping Practitionershavetoactivelychallenge

stereotypesthatBMEserviceusers

maybevulnerableto.Inriskwork,BME

serviceusersshouldbeenabledto

makedecisionsaboutrisksintheirlives

andpractitionersshoulddemonstrate

theirconcernforthesafetyandwellbeingofserviceusers.

ESC 4 - Challenging

Inequality

ESC 9 - Promoting Safety

& Positive Risk Taking



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6. Migration Giventheextremelypooraccessto

mentalhealthservices,thereisan

urgentneedforpractitionerstowork

closelywithrefugeeandasylum

seekergroupstoimproveaccess.Constructivepartnershipsneedtobe

builtbetweennewlyarrivedgroups

andlocalcommunitiesandmental

healthserviceshaveanimportant

roletoplayinthistask.Thisareaof

mentalhealthworkisinvolvesrapidly

changing practice due to conicts and

worldwideeconomicfactorswhichwill

requirepractitionerstokeepabreast

ofresearchandnewmentalhealth

approachesinmigration.

ESC 1 - Working in

Partnership

ESC 10 - Personal

Development & Learning

Ifyouareinclinicalwork-thinkofarealBMEserviceuseryouhaveworkedwithorknow

aboutandanswerthefollowingsixquestionswhichcorrespondtothesixkeyfactors.Once

youhaveansweredthequestionsaboutthepersontickoneortwoofthemostimportantkey

factorsforthatpersononthegrid.

Key Factors A BME service user tick

.Compulsion

Howdidtheserviceuser

enterintomentalhealthservices?

2. Prevention

Whatkindofhelpinthe

communitymayhave

preventedthepersonfrom

enteringacutementalhealth

services?

3.Diagnosis

Doesthepersonagreewith

theirdiagnosisandhowdoess/hedescribetheir

mentaldistress?

4.Treatment

Whatkindoftreatmentshas

thepersonbeenofferedand

usedmainly?

5.Stereotyping

Doyoufeelthattheperson

hasbeensubjectedtoany

stereotypes?Ifsowhat?



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6.Migration

Hasthepersonortheir

familybeenaffectedbythe

experienceofmigration?If

sohow?

Whatcouldhavebeendonedifferentlytoimprovetheexperienceofthatpersoninmental

healthservices?



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4.Breakingthecirclesoffear

Therearemanyreasonsfortheover-representationofBMEpeopleinmentalhealthservices

andtheirexperienceofdifferentstandardsandoutcomesinservicedelivery.Socialand

politicalfactorsplaytheirpartasdoissuesconcerningpower,economicdisadvantageandsocialexclusion.

Thedegreeoftheproblemfacingmentalhealthservicesischaracterisedbyarecentstudy

abouttheexperienceofAfrican-CaribbeanpeoplebytheSainsburyCentreforMentalHealth

(SCMH2002,BreakingtheCirclesofFear).

WhattheSCMHhastermedcirclesoffearhavebeencreatedsothat:

manypeople,particularlyintheBlackAfricanandCaribbeancommunities,donotbelieve

thatmainstreammentalhealthservicescanofferpositivehelp,sotheydelayseekinghelp;

theythereforearenotengagingwithservicesatanearlypointinthecyclewhenthey

couldreceivelesscoerciveandmoreappropriateservices,cominginsteadtoservicesin

crisiswhentheyfacearangeofrisksincludingoverandmisdiagnosis,policeintervention

anduseoftheMentalHealthAct;

these aversive care pathways further inuence both the nature and outcome of treatment

andthewillingnessofcommunitiestoengagewithmainstreamservices.

(DeliveringRaceEquality:AFrameworkforAction,DoH,October2003,page8)

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.

ThethreekeythemesthatemergedfromtheCirclesofFear(SCMH2002)researchwere:

TherearecirclesoffearthatstopBlackpeoplefromengagingwithservices

Mainstreamservicesareexperiencedasinhuman,unhelpfulandinappropriate

Problematic care pathways of Black people inuence the type and outcome of

treatmentandthewillingnessofthesecommunitiestoengagewithmainstream

services

Asmentalhealthpractitioners,weneedtothinkaboutourassumptionsaboutpeoplewe

considertobedifferentbecauseoftheirracialorculturalbackgrounds.Thisincludesthe

wayweunderstandwhatismeantbyraceandculture.Weneedtobeawareofhowthese

understandingscanleadustohavenegativeviewsofsomepeoplewecomeintocontact

with. We also need to understand how these views inuence the way we deal with a diverse

rangeofpeople.Beingawareofthesethingshelpsustounderstand,respectanddealwith

serviceusers,theirfamiliesandcarersinafairmanner.

Activity5.5.

Consider how fear may inuence decisions relating to the following procedures:

Riskassessment(relatestoESC9)



21/26


Useofmedication

Controlandrestraint

Referralstoseclusion,psychiatricintensivecare,orSpecialHospitals

(forfurtherreadingsee:Keating,FrankandRobertson,David(2004)Fear,blackpeopleandmentalillness:aviciouscircle?Health and Social Care in the Community; 12 (5): 439-447)

Activity5.6.

ReadthroughthefollowingandconsiderwhichoftheESCsthesestatementsrelateto:

AfricanCaribbeanserviceusersandcarersrepeatedlyasktobetreated

withrespectanddignity.Theydemandbetterinformationaboutserviceswith

lesscoercion,lessrelianceuponmedicationandotherphysicaltreatmentsandmorechoice.Inthistheyconcurwiththeviewsofmanyotherservice

usersandcarerswhohavecommentedontheirexperienceofmentalhealth

services.Theywishtobetreatedandrespectedasindividuals.From

BreakingtheCirclesofFear,SainsburyCentreforMentalHealth,2002

African Caribbean service users and carers repeatedly ask to be treated with respect and

dignityrelatestoESCnumber/s:

They demand better information about services with less coercion, less reliance upon medi-

cation and other physical treatments and more choice.relatestoESCnumber/s:



22/26


5.DeliveringRaceEquality

Inside Outside(DepartmentofHealth2003)signalledreformofmentalhealthcareforBME

communities.

It was prepared by some of the leading people in the eld and was supported bywidespread public consultation. It identied three key objectives:

toreduceandeliminateethnicinequalitiesinmentalhealthserviceexperience

andoutcome;

todeveloptheculturalcapabilityofmentalhealthservices;and

toengagethecommunityandbuildcapacitythroughcommunitydevelopment

workers.

Delivering Race Equality(DepartmentofHealth2003)proposedkeystrategic,whole

systemresponsestoInsideOutsidetoimplementthereformitsignalled.Itdescribedthree

mainbuildingblocks,closelyrelatedtotheobjectivesofInside Outside,whichnowformthe

foundationsofanactionplan:

thedevelopmentofappropriate,sensitiveandresponsiveservices;

theengagementofBMEcommunitieswithserviceproviders;and

good quality, intelligently used information on the ethnic prole of local

populationsandofserviceusers.

TheGovernmentsFiveYearPlanforachievingraceequalityandtacklingdiscriminationin

mentalhealthservicesinEnglandisthemostimportantpolicystatementonBMEmental

health.

Itaimstoachieve:

LessfearofmentalhealthservicesamongBMEcommunitiesandserviceusers

Increasedsatisfactionwithservices

AreductionintherateofadmissionofpeoplefromBMEcommunitiesto

psychiatricinpatientunits

AreductioninthedisproportionateratesofcompulsorydetentionofBMEservice

usersininpatientunits

Fewerviolentincidentsthataresecondarytoinadequatetreatmentofmental

illness

AreductionintheuseofseclusioninBMEgroups

ThepreventionofdeathsinmentalhealthservicesfollowingphysicalinterventionMoreBMEserviceusersreachingself-reportedstatesofrecovery;

Areductionintheethnicdisparitiesfoundinprisonpopulations;

Amorebalancedrangeofeffectivetherapies,suchaspeersupportservices

andpsychotherapeuticandcounsellingtreatments,aswellaspharmacological

interventionsthatareculturallyappropriateandeffective;

AmoreactiveroleforBMEcommunitiesandBMEserviceusersinthetrainingof

professionals,inthedevelopmentofmentalhealthpolicy,andintheplanningand

provisionofservices

Aworkforceandorganisationcapableofdeliveringappropriateandresponsive

mentalhealthservicestoBMEcommunities.



23/26


Activity 5.7.

BecominganallytoBMEserviceusers

ThelistofDREaimsprovidesausefulframeworktojudgehowwellservicesaredoinginrelationtoBMEpeople.Practitionerswhoincreasetheirknowledgeoftheseindicatorsfor

BMEmentalhealthcanbecomepowerfulalliesforBMEserviceusersintheirareaandact

tosafeguardtherightsoflocalBMEpeopleinthementalhealthsystem.Knowledgereallyis

powerandthechecklistbelowisareminderofsomekeyquestionsthatpractitionersshould

beaddressingiftheywishtogainsomepowerinchallenginginstitutionalracismintheir

area.

Answerasmanyofthefollowingquestionsasyoucanandworkouthowyouwillgetthe

informationrequiredtoanswerallofthem.

Supporting Delivering Race Equality Where will you get this

information?

. WhatdoBMEserviceusersthinkabout

yourservice?

2. WhatistherateofadmissionofBME

peopletoyourlocalpsychiatricin-patient

units?

3. Whataretheratesofcompulsorydetention

ofBMEserviceusersinyourlocalin-

patientunits?4. Whatisthenumberofrecordedviolent

incidentsinvolvingBMEpeopleinmental

healthfacilitiesinyourarea?

5. HowoftenisseclusionusedwithBME

serviceuserswithinin-patientfacilities?

6. Whatisthenumberofdeathsinmental

healthservicesfollowingphysical

interventionoverthepasttenyears?

7. WhataretheviewsofBMEserviceusers

abouttheirrecoveryfrommentaldistressandhowserviceshavehelpedthem?

8. Whatistheethnicbreakdownofthemost

localprisoninyourarea?

9. Whatculturallyappropriateandalternative

therapyservicesarethereinyourarea,

includingtalkingtherapies,whichare

availableandaccessibletoBMEpeople?

0. HowoftenandinwhatwaysareBME

serviceusersandcarersinvolvedinthe

trainingofmentalhealthpractitionersin

yourarea?



24/26


. Whattraininganddevelopment

opportunitiesarethereforpractitioners

inrelationtoRaceEqualityandCultural

Capability?

Howcanyoumosteffectivelyuseyournewly-foundknowledgeofBMEmentalhealthissues

tobringaboutchangeinyourservice?

Thismodulewillprovideyouwithagoodunderstandingofsomefundamentalissuesand

prepareyoufortheRaceEqualityandCulturalCapabilityfoundationtrainingmaterials

whichextendandexamineingreaterdepthmanyoftheissuescoveredinthisESCmodule.

5.Linkstofurtherlearning

ReferencesCommissionforRacialEquality(2006),Common Ground: Equality, good race relations

and sites for Gypsies and Irish Travellers - Report of a CRE inquiry in England and Wales,

London,CommissionforRacialEquality.

DemirJ.,(2003)quotedinKeatingF,RobertsonD&KotechaN(2003) Ethnic Diversity and

Mental Health in London - Recent developments.KingsFund.

DepartmentofHealth(2003)DeliveringRaceEquality:AFrameworkforAction.Mental

HealthServicesconsultationdocument,London,DepartmentofHealth.

DepartmentofHealth(2005)Deliveringraceequalityinmentalhealthcare:AnactionplanforreforminsideandoutsideservicesandtheGovernmentsresponsetotheIndependent

inquiryintothedeathofDavidBennett,London:DepartmentofHealth.

Note: David Bennettwas 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.

DepartmentofHealth,June2003,Caring for Dispersed Asylum Seekers: A Resource Pack

London,DepartmentofHealth.

DepartmentofHealth(2003)InsideOutside:ImposingMentalHealthServicesforBlackand

MinorityEthniccommunitiesinEngland,London,DepartmentofHealth.

FernsP.(2003)Letting Through Light A service user-led Audit in Ealing,publishedby

LitTleProject.WestLondonMentalHealthNHSTrustandEalingSocialServices

FernsP.(2000)inRace&MentalHealth,inBaileyD.(ed), At the Core of Mental Health,Brighton,Pavilion



25/26


Keating,Robertson&Kotecha(2003), Ethnic Diversity and Mental Health in London -

Recent developments,KingsFund

Macpherson,W.(999)The Stephen Lawrence Inquiry:ReportofanInquirybySir

WilliamMacphersonofClunyadvisedbyTomCook,TheRightReverendDrJohnSentamu, Dr Richard Stone. London, The Stationery Ofce

NazrooJ.&KingM.(2002)Psychosissymptomsandestimatedrates.InKSproston

andJ.Nazroo(Ed.) Ethnic Minority Psychiatric Illness Rates in the Community (Empiric).

NationalCentreforSocialResearch,TSO

SainsburyCentreforMentalHealth(2002) Breaking the circles of fear. a review of the

relationship between mental health services and African and Caribbean communities.

London:SainsburyCentreforMentalHealth

Wilson M. and Francis J. (1997), Raised Voices: African Caribbean and African Users Viewsand Experiences of Mental Health Services in England and Wales,MIND

N.B. TofollowfromthismoduleNIMHE/CSIPandCCAWIwillbepublishingsubstantial

learning materials on Race Equality and Cultural Capability in 2007.



26/26


Documents

ESC Module 5