mental ill- health at some time in our lives (WHO, 2001). Mental Health is ” used positively to indicate a state of psychological well- being, negatively to indicate its opposite ( as in ‘mental health problems’) or euphemistically to indicate facilities used by, or imposed upon , people with mental health problems ( as in ‘mental health services’).
During the nineteenth century, all patients were certified under lunacy laws. That is, the State only made provisions for the control of madness. The fledgling profession of psychiatry ( this term was first used in Britain in 1858) was singularly preoccupied with segregating and managing lunatics . With the emergence of the First World War, soldiers began to break down with ‘shellshock’ now called ‘post – traumatic stress disorder’ . From this point on, psychiatry extended its jurisdiction from madness to versions of nervousness provoked by stress or trauma. In the twentieth century, more abnormal mental states came within its jurisdiction, such as those due to alcohol and drug abuse and personality problems. Today, ‘mental health services’ may be offered to, or be imposed upon, people with this wide range of problems, although madness or ‘severe mental illness’ still captures most of the attention of professionals .Another aspects of the term ‘mental health problems’ is that some people, critical of psychiatric terminology, object of scientific or logical grounds to notions like ‘mental illness’ or ‘mental disorder’.
In the 1983 Act and equivalent Scottish legislation ‘ mental illness’ is not defined. However, Article 3(1) of the Northern Ireland Order does define it as ‘ a state of mind which affects a person’s thinking, perceiving, emotion or judgement to the extent that he requires care or medical treatment in his own interests of other persons’. Neither the Scottish nor Northern Ireland definitions include psychopathic disorder and there has recently been some discussion in the context of review of the Mental Health Act about removing it in England and Wales.
Issues concerning mental health have been raised substantially in the consciousness of politicians, the media, and the public. Moreover, the ‘burden’ of mental disorder is regarded not just as a – if not the- principal cause of human misery, but as a significant impediment to social and economic growth. Measurement of the years of potential life lost and the years of productive life lost through mental ill- health could reach 15% of all diseases and deaths globally by 2020 (WHO, 1999).
A further dimension of inequalities in the apparent scale of mental health problems is race. Race is controversial to define. Genetic distinctions between groups of humans ( other based on sex) have little empirical basis. Racial distinctions arose from anthropological investigations carried out by colonized indigenous people. However, because of colonization, the social identity of these people became real for them and others.
In the United States black patients are overrepresented in mental institutions, and have become increasingly so over the postwar period. This has particularly been the case within state mental hospitals, where minority groups constitute 35 per cent of the hospital population, and are subject to higher rates of admission and readmission. In a review of eight epidemiological studies conducted in the United States between the late 1950’s and mid- 1970’s, Kessler and Neighbors (1986) found that among persons with low incomes black people exhibited significantly more distress than white people. They claimed, therefore, that race is an important independent variable in determining the likelihood of an individual becoming mentally ill. There is some dispute over what to make of this evidence. Cockerham (1990) maintains that the majority of studies on the incidence and distribution of mental health problems suggest that race is not an independent variable:…’ race alone does not appear to produce higher rates of mental disorder for particular groups’. Rather, it is because more black people are in the lower social cases that they tend to demonstrate more signs of mental distress. Others, however, disagree. Halpern (1993) argues that minority status can be demonstrated to result in a tendency towards psychiatric problems.
As with gender, a number of studies have been conducted indicating that racial bias exists in the assessment, diagnosis and treatment of mental health problems. It has been found, for example, that white therapists generally rated their black clients as being more psychologically impaired than did black therapists. Patients who are uncooperative, threatening or abusive are more likely to be diagnosed as being mentally ill if they have minority status. In particular, it has been found that being black tends to increase the chances of a person being diagnosed as being schizophrenic (Wade, 1993).
Certain groups such as people of Afro- Caribbean origin tend to be more likely than whites to receive psychotherapy. Minority groups have proved less able to make use of community- based services. This is partly because they have lacked the resources to participate in the development of community care, and partly because of the lack of interest in or understanding of the specific cultural needs of minority groups when establishing services ( Wade, 1993).
The term Afro- Caribbean refers to black people who either still live in Caribbean or who moved to Britain. Britain is an ex-colonial power, which enslaved and forcibly transported African people. Afro-Caribbean people have higher rates of diagnosis for schizophrenia but lower rates for depression and suicide than indigenous whites. An unresolved debate about over- representation is whether it is actual ( black and Irish people are mad more often) or whether it is a function of misdiagnosis .
The data of Irish people highlight why the stresses of racism, based purely on skin colour, are not an adequate explanation of differences in mental health status. Although Afro- Caribbean people are vulnerable to psychosis, prevalence rates of all diagnostic categories are higher than for the indigenous ( non- Irish)whites in Britain.
What are the implications of comparing and contrasting these two ex-colonized groups for our understanding of the relationship between race and mental health? The first point to emphasise is that given the white skin of the Irish, racism based on skin colour may be a stressor but is not one that accounts for racial differences in mental health. A second point is that while both groups are post-colonial remnants of forced migration, the circumstances for each were different. Third, the circumstances of migration to Great Britain were similar in some ways but not others. Employment opportunities governed population movement in each. Fourth, as ex-colonized, Afro- Caribbeans and the Irish have been recurrently stigmatized and rejected. A confirmation of this point is that these groups are also over-represented in the prison population, not just in involuntary specialist mental health services. Fifth, and following the previous point, whatever the causal explanations for over- representation, the racial bias means that these groups are disproportionately dealt with by specialist mental health services. As the latter are dominated by coercion, this outcome can be thought of as a form of structural disadvantage for these groups.
The needs, issues and concerns of ‘black’ and minority ethnic people (BME) with mental health problems have been pushed to the fore of the national health policy agenda (Department of Health, 1999; Department of Health, 2005). Britain is a multi- cultural society where the percentage of the population that is from minority groups is steadily increasing. In 2001 minority groups comprised seven per cent of the population, with a concentration in London and other inner city areas.
BME communities occupy particular positions of disadvantage in the United Kingdom. Inequalities are reflected across all indices of economic and social well- being.They generally have higher rates of unemployment, live in poorer housing, report poorer health, have lower levels of academic achievement and higher rates of exclusion from schools.
The tragic but significant marker for BME communities was the death of David Bennett while being restrained by nursing staff on a medium secure ward. After a long campaign by his family, an independent inquiry report concluded that the NHS mental health services are ‘institutionally racist'( Norfolk, Suffolk and Cambridgeshire SHA, 2003). The government subsequently published an action plan for Delivering Race Equality (Department of Health,2005). This plan has three building blocks: to develop more appropriate and responsive services, to provide better quality information on the mental health needs of BME, to encourage greater community engagement in the planning and delivery of mental health services. DRE focuses on organisational change, but fails to appreciate the heterogeneity within the BME population, and the complex range of identities and practices it contains.It also fails to appreciate that the inequalities in mental health for black people exist within a broader historical and contemporary context of social and economic inequalities and prejudice. Moreover, the problem seems to have been framed in the context of culture- thus, the focus in the DRE strategy on developing a culturally competent workforce. Fernando (2003) argues that a focus on culture can itself be racist and therefore has to be examined in this context.
Another issue to consider is the impact of racial disadvantage and discrimination on individuals , their families and communities. Petel and Fatimilehin (1999) suggested that the impact of racism is psychological, social and material. The effects of these are likely to be detrimental to mental health, but it has to be borne in mind that for some it may be minimal, while for others it may be of great significance to their emotional well-being. The effects of racism on the individual may have wider impacts on families and communities . The impact of racism therefore has to be analysed in the context of histories of migration, histories of alienation, the subordination that resonates for these groups, and the way in which these groups have been stigmatised and continue to be stigmatised in society today.
There are many competing discourses and perspectives on what constitutes mental illness. Bracken and Thomas (2005)argue that our knowledge of mental illness and distress is indeterminate and new ways of thinking about mental illness are constantly emerging. Coppock and Hopton (2000)suggest that there is ample evidence to show that mental illness is affected by social and political circumstances. Mental illness can be deeply dehumanising and alienating. It is generally regarded with anxiety and fear and loads to rejection and exclusion. A report by the Social Exclusion Unit (2004) found that people with mental health problems are among the most disadvantaged and socially excluded groups in society.
The stereotype of ‘ big and dangerous’ has been fixed in the popular case of Christopher Clunis- a back man who had a diagnosis of schizophrenia, who randomly killed a stranger to him, Jonathan Zito, in a London underground in 1992. Keating et .al (2002) have demonstrated that such stereotypical views of black people, racism, cultural ignorance, stigma and anxiety associated with mental illness often combine to influence the way in which mental health services assess and respond to the needs of BME communities. There are at least three factors that underpin black people’s experiences of the mental health system: one, how black people are treated in society; two, how people with mental health problems are treated in society and three, the power of institutions to control and coerce people with mental health problems. Black people’s experiences in society have an impact on their mental and emotional well- being; these experiences in turn influence how they experience and perceive mental health services, and their position in society affects how they are treated in mental health services.
Eradicating the disparities in mental health treatment and outcomes for a black people requires change in individual practices, but this can only be successful if supported by changes at the organisational level. Efforts to improve mental and emotional well- being for BME communities should be anchored in an understanding of history, broader societal conditions and contexts, and black people’s lived experiences: not just their experiences of racism, but also how they have survived in the face of multiple adversities.
McKenzie (2002) has argued that the lack of definition of mental health from a British African Caribbean perspective and the ‘ use of diagnostic criteria based on white European norms rather than on the values and experience of the African- Caribbean population’ is problematic.
Further evidence Hunt (2003), Keating, Robertson and Kotecha (2003) and McKenzie (2002) suggests that people from BME communities experience a number of social and environmental risk factors which adversely affect their mental health. These include high unemployment rates: poor housing, racism, low educational expectations, particularly for African and Caribbean boys (Grater London Authority/ London Health Observatory 2002); isolation; and a lack of access to opportunities for personal development.
A report by the black mental health charity Footprints (UK) (2003), which works primarily with African Caribbean service users, has identified continuing issues of concern about care and treatmet as: the need for better assessment to promote more culturally acceptable interventions, concerns about medication, including high dosages and polypharmacy, resulting in numerous adverse side- effects and negative staff attitudes.
Keating et al. (2003) have highlighted the point that black people see using mental health services as a degrading and alienating experience and that their perception is that service respond to them in ways that mirror some of the controlling and oppressive dimensions of other institutions in their lives, for example exclusion from schools and contact with police and the criminal justice system.
The National Service Framework for Mental Health ( NSFMH) is an important driver and ways a key step in actively signalling that health services must ensure that the needs of people from BME communities are incorporated in the planning processes from mental health care. The framework emphasised the need for diverse communities to be consulted about the ongoing effectiveness and suitability of services.
The NHS Plan is underpinned by ten core principles that are aimed at ensuring that people who use mental health services are at the centre of determining how services are delivered. The NHS Plan contains an explicit recognition of the diversity that exists within Britain.
The recently published strategy on black mental health again underscores the government’s commitment to race equality and outlines the underpinning roles of the NSFMH and the NHS Plan in ensuring that its modernisation programme within mental health is delivered.
In conclusion the impetus and improvement for mental health service delivery to BME communities can be seen. Many people who use mental health services, however, would argue that what is less tangible is change in hospital wards, day centres, residential homes and engagements with community mental health teams; in essence, at the coal face. There is scope for substantial and sustainable change. It will require a recognition by mental health professionals of the strengths that service users and their families can bring in reshaping service delivery, partner- professionals and, most importantly, agreement by service providers and service users on clear and mutually agreed goals and outcomes about what constitutes improved care and treatment. Efforts to improve mental and emotional well- being for BME communities should be anchored in an understanding of history, broader societal conditions and contexts, and black people’s lived experiences: not just their experiences of racism, but also how they have survived in the face of multiple adversities.
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