Cultural Competence in Mental Health Services. If only we were told.Year 2

Overview. Key Reports on Health Care 2012-3
"Compassionate Care"
1.1 Key recommendations of the report into the death of David Bennett, which appeared at the beginning of 2004, emphasise training in cultural competence. They state:

(i) All who work in mental health services should receive training in cultural awareness and sensitivity.

 

(ii) All managers and clinical staff, however senior or junior, should receive mandatory training in all aspects of cultural competency, awareness and sensitivity. This should include training to tackle overt and covert racism and institutional racism.

(iii) All training referred to in 1 and 2 above should be regularly updated.

 

1.2 The Government initiative "No Health Without Mental Health" 2011 also reports that BME communities across the UK request increased cultural competence in services. All participating Black and minority ethnic communities point to a strong need for greatly increased cultural competency in mental health services. Study participants highlighted the need for practical improvements in language (interpreting, translating, literacy support), meeting faith-related and religious needs, culturally appropriate food, gender-specific services and staff, increasing the ethnic diversity of staff, and action to tackle racism." No Health Without Mental Health 2011
1.3 The first year report "If only we were told" looked at mental health initiatives over a decade. The David "Rocky" Bennett report led directly to key initiatives in equality in mental health provision. particularly "Delivering Race Equality" and "Count Me in" statistics. These annual reports gave evidence of marked and unacceptable differences in equality in access to appropriate services.
"If only we were told report -year 1

1.4 New programmes of treatment, such as "Increasing Access to Psychological Therapies" were thought to be major advances, yet BME communities are saying that they have not benefitted from them.

1.5 Evidence shows that different sections of the community are likely to follow different paths in accessing mental health treatment. More African Caribbean people access mental health treatment through the criminal justice system ending up in secure units and prisons. Asian communities say they too find difficulty getting treatment that recognises different cultural, religious and linguistic understanding of mental health.
Improving Access to Psychological Therapies. A review of the progress made by sites in the first roll‐out year

1.6 A consequence of failure to address cultural competence can be misdiagnosis. This, according to practitioners such as Dr Aggrey Burke continues to be a hazard between clinician and patient where there is cultural confusion. This is compounded by commonly held ideas and beliefs about black people and mental health and applying labels as a result of stereotypical understanding of conditions such as schizophrenia.

1.7 Different traditions may have their own ways of dealing with well being, Much is made of reporting the widespread existence of stigma and fear, and supposed cultural shortcomings, much less attention is given to different coping strategies which if understood and taken up by professionals could greatly help improved well being of patients.

1.8 In 2012-13 health care issues were dominated by two reports of major failures in care. The Francis Report into failings at the Staffordshire Hospital Trust was followed by the Winterbourne View report of abuse of patients in care homes. Resulting from these and other reports of breakdowns in care to vulnerable people came a response from the Government with the call for "Compassionate Care".

The failure to deal with inequalities in mental health
Increasing Access to Psychological Therapies (IAPT)

1.9 While there have been significant advances in mental health treatment over the last decade, similar advances in addressing equalities have stayed stubbornly static with identifiable pathways to services differing between cultural groups. One major initiative has been the IAPT (Increasing Access to Psychological Therapies) but feelings of many are that they have been excluded from benefitting from these treatments and are consigned to medical remedies, coercion and detention. While there has been a move away from a medical model of care competence in recognising varying perceptions of mental health according to culture is still largely missing. Whether this is due to absent mindedness or more deliberate racist attitude it is necessary to create a climate of understanding and refusal to tolerate willful acts of violence by agency staff serving the public.
Coercion in Mental Health

1.10 Referrals to mental health services will likely be from various other agencies and sources for a variety of reasons. Social services, police, prison services, schools and colleges all deal day to day with people and it is expected that within their training they will be competent to recognise those at risk from difficulties such as poor mental health. A number of questions arise.

1.11 If cultural competence is missing from the range of competencies needed in working in a diverse community then there is added risk. Even within the health service people can be labelled and prejudice results. This we know that black men in particular are associated with "schizophrenia". The case of Kingsley Burrell who died while being held in a secure mental health unit in Birmingham in 2010, was taken there by police after he had called them for support when he felt under threat from a group of youths. The police judged him to be paranoid, beat him according to his young son who was with him, and he was sectioned as a result. His family say there was no previous knowledge of mental health problems. He later died in mysterious circumstances that have still to be explained. 10 years on from the David Bennett Report and cases of many people with or some without mental health histories and a high proportion of black men have died in custody. No reports have been commissioned and indeed in many cases there are suspected cover ups.

1.12 It is of deep concern that threats of "sectioning" is used as a weapon when dealing with people as some black women in the West Midlands have alleged in their dealings with police. In one case the threat was carried out, the family unable to find her whereabouts.

1.13 In some of these examples it appears that racism may be a factor for those dealing with people using mental health issues improperly. Of course in order for this to work institutional back up is essential. Police superiors, courts, prison officers and even trained clinicians seem happy to oblige. This matter is in urgent need of independent investigation.

2. Cultural Competence - some definitions
The importance of cultural competence

2.1 In 2007 Professor Kamaldeep Bhui et al surveyed the availability of courses of study addressing cultural competence. They discovered only 9 programmes of study with outcomes evaluated to demonstrate they had been effective:
2.2 Abstract of research programme
"Background: Cultural competency is now a core requirement for mental health professionals working with culturally diverse patient groups. Cultural competency training may improve the quality of mental health care for ethnic groups.
Methods: A systematic review that included evaluated models of professional education or service delivery.
Results: Of 109 potential papers, only 9 included an evaluation of the model to improve the cultural competency practice and service delivery. All 9 studies were located in North America. Cultural competency included modification of clinical practice and organizational performance. Few studies published their teaching and learning methods. Only three studies used quantitative outcomes. One of these showed a change in attitudes and skills of staff following training. The cultural consultation model showed evidence of significant satisfaction by clinicians using the service. No studies investigated service user experiences and outcomes.
Conclusion: There is limited evidence on the effectiveness of cultural competency training and service delivery. Further work is required to evaluate improvement in service users' experiences and outcomes."
Source

2.3 The research paper looks at the selected papers to see if a pattern emerges to say what cultural competence is. The conclusion they reach is that it is about practitioner and patient understanding each others cultural viewpoints, the absence of which can lead to misdiagnosis, or mismanagement of care provided. It is extremely complex in practice and subject to oversimplification and misconception. It is not, for example, just a matter of knowing about different faiths and cultures, their symbols and practices, rather it is coming to an understanding of how cultural difference can lead to different concepts of mental illness. It is understanding how different family structures and traditions affect individuals. Different individuals within any one cultural will vary so no formulae are likely to help. There are differences between age groups.

2.4 A model developed by BEWEG likens "cultural competence" to an iceberg where the visible tip is what is commonly accepted as its meaning while what really matters is what lies out of sight below the surface. The authors also point out that there is often an expectation of having practitioners and patients with common cultural backgrounds is the answer. This is unrealistic because the practitioners will most likely have been trained in the same way.

2.5 The following is from a source in the United States talking about cultural competence and why it is of fundamental importance:

"Cultural competency is one of the main ingredients in closing the disparities gap in health care. It's the way patients and doctors can come together and talk about health concerns without cultural differences hindering the conversation, but enhancing it. Quite simply, health care services that are respectful of and responsive to the health beliefs, practices and cultural and linguistic needs of diverse patients can help bring about positive health outcomes."
Source

2.6 The Government's "No Health Without Mental Health" stresses in the foreword under the names of David Cameron and Nick Clegg:

"The Prime Minister, David Cameron, and the Deputy Prime Minister, Nick Clegg, have made it clear that the Coalition Government's success will be measured by the nation's wellbeing, not just by the state of the economy. The public health White Paper Healthy Lives, Healthy People is the first public health strategy to give equal weight to both mental and physical health.This Government recognises that our mental health is central to our quality of life, central to our economic success and interdependent with our success in improving education, training and employment outcomes and tackling some of the persistent problems that scar our society, from homelessness, violence and abuse, to drug use and crime."

 

On inequality the report has this to say:


"Critically, not all groups have benefited equally from improvements - for example, many
people from black and minority ethnic communities. Access to services is uneven and some people get no help at all. This contributes to health inequalities within and between groups with 'protected characteristics' "

No Health Without Mental Health p 8. 1.11

 

2.7 However good intentions are evidence of the present state of mental health provision is of a crisis. Since the Talk to Us project, 2007, many of the voluntary sector organisation "set up because of unmet need" (Ralph Hall of CSIP) have lost key staff. "Delivering Race Equality and the Count Me In statistics have been archived as if no longer relevant. While it is clear that the programmes failed to meet expectation the knowledge gained needs to be developed, not discarded.

3. David Bennett: the report 10 years on
3.1 While the present Government's plans make it very clear that the same issues continue to exist it is as if they are treating the efforts to deal with it as political. Two issues illustrated here by case studies show that:

(i) Issues of Mental Health in the African Caribbean community continue to feature, although they fail to get the public attention that followed the death Stephen Lawrence, if not that of David Bennett. Of deaths in custody since the David Bennett report a significant number have been African Caribbean. Far from getting reports written they have characteristically been followed by cover ups. Many have been related to mental health issues, although some of the victims were not known to have a prior history of illness. This prompts the question of diagnosis and understanding when terms like "schizophrenia" are routinely attached in a way that becomes stereotypical. The question arises are members of this section of the community at risk from being mistreated based on prior assumptions and racist attitudes? The cases of Mikey Powell and Kingsley Burrell in Birmingham and police practice in Wolverhampton will be considered here.

(ii) Members of Asian communities have noted that the Delivering Race Equality agenda highlighted the failure of services to offer effective mental health services to the African Caribbean community. They feel that the characteristics of this failure are increasingly applicable to them, but with important differences. In particular advances in treatment such as IAPT it is felt have not been readily available, and may not take account of cultural or linguistic differences. The question of "cultural competence" is highlighted, with doubts that while it is said to be important it is widely misunderstood, dealing only with the visible tip of the iceberg model rather than underlying factors.


3.2 Cases in Birmingham and Wolverhampton over the period since the Bennett Report question what, if anything, has been learned? What has improved?

The death of Mikey Powell in 2003 when the ink on the David Bennett Report was not yet dry. It then took 6 years to decide that he died as a result "positional asphyxia".

Now 10 years on the family has received an apology from the police. On the other hand no one has been called to account. As usually happens officers involved have retired from the police force and just faded out of sight.

The following is an account from the Friends of Mikey Powell Campaign for Justice.

"Mikey Powell was 38 years old when he died after being detained by West Midlands Police on 7 September 2003. He had three children. He had a mental health crisis and smashed a window at the home he shared with his mother. His mother called the police for help, assuming they would take him to hospital.
During the incident that followed, the police drove a car at Mikey as fast as they could, claiming they thought he had a gun, which he did not. Mikey was injured but survived the collision. He was then sprayed with four times the recommended amount of CS gas, hit with a baton and restrained for at least 16 minutes. No ambulance was called. Mikey was put on the floor of the police van and taken to the police station and into a 'drunk cell'. It was only then officers noticed that he was not breathing.
The inquest jury found that Mikey died of positional asphyxia in the back of the police van while he was being taken to the police station.
Many issues were raised by the inquest into his death, including questions around possible assumptions made by police about Mikey, based on the area he was living in and the colour of his skin. The family made several recommendations following Mikey's death, including training for officers to avoid these kinds of assumptions being made."

Mikey Powell was not a criminal, He lived in the Lozells district of Handsworth which itself has a history of associations with black people. While events in 1981 and 1985 received sensationlised media coverage, attributing "rioting" to the black population, those seen in court came a variety of backgrounds, age groups and areas outside both Handsworth and Birmingham. As one resident said at the time, the impression was given that "we routinely had drugs with our cornflakes". Mikey was a much loved family member but who was experiencing a mental health problem. It was his Mother who called the police for assistance, hardly expecting the response described above. She continues to regret her decision that day in September 2003.
As stated it took years to establish the cause of Mikey's death: that it was not being hit by a police car, using excessive amounts of CS gas, being hit repeatedly with police batons or being sat on by a number of police officers. It has taken longer for an apology, but as yet no one has been called to account and held responsible. The family have made recommendations, but it is not clear if these have been accepted an shared. Meanwhile the recommendations of the David Bennett enquiry remain together with information now archived.

 

3.3 On 27th March, 2011 another member of the African Caribbean community died while in custody. He had no previous history of mental illness but ended up being sectioned and detained at the Mary Seacole Centre in the Winson Green area of Birmingham. On this occasion he himself had called the police when he felt that he and his young son were being threatened.
Kingsley Burrell, 29, dialled 999 after being threatened by a group of men while with his young son in Icknield Port Road, Birmingham, on March 27 last year.

But when officers turned up they detained the trainee security guard under the Mental Health Act - despite his family saying he had no history of mental illness.

Within hours Mr Burrell was sectioned and taken to a mental health unit in the city, where his family claim he had mysterious physical injuries and was not allowed to speak to them.

Three days later, police were called to the Mary Seacole mental institute in Winson Green after an "incident" involving the dad-of-two and he was transferred to the Queen Elizabeth Hospital, where he died on March 31.

The Independent Police Complaints Commission immediately launched an inquiry and has now asked Dorset Police to begin a further investigation into the death.

Last night Mr Burrell's sister, Kadisha Brown-Burrell said the family still had no idea how he had died - and could still be months away from having a funeral.

She said:

"How can they keep a body for a year? It's been more than a year now and they are dragging their heels.

 

''We are still grieving and need closure but have been told the Dorset Police investigation will take at least take another six months.

"We're angry and frustrated and don't know what is happening.

''It's been painstakingly difficult, frustrating, and emotionally overwhelming for the family to begin to come to terms with his death. Especially, not being able to lay his body to rest, not knowing the sequence of events that led up to his death and how he died.''

Mr Burrell was dad to five-year-old son Kayden - who was with him when he was detained by police - and 10-year-old daughter Travita.

Student Miss Brown-Burrell regularly visits her brother's body, which is being held at the mortuary at Sandwell Hospital.

She added: "I personally don't have much confidence in the IPCC investigation and we have not been kept informed.

"The family has now attended eight or nine pre-inquest hearings, yet still nobody can tell us what or who killed Kingsley.

''It's not fair on his children, especially his little boy who can't stop thinking and talking about what happened that day."

A spokesman for the IPCC said investigators have interviewed four West Midlands police officers under criminal caution and a further 10 officers as witnesses.

He added: "In total, more than 100 witness statements have been obtained from police officers, medical professionals, ambulance staff and members of the public.

''Footage from CCTV cameras at four locations has been recovered and reviewed and hundreds of documents have been seized as part of the independent investigation.

"Earlier this year, after liaison with HM Inspectorate of Constabulary, Dorset Police were requested by the IPCC to begin an investigation into the actions of non-police personnel who had contact with Mr Burrell and they continue to undertake enquiries.

"The IPCC has provided regular updates at HM Coroner's pre-inquest hearings and to the family and interested parties.'"

 

Kingsley Burrell's funeral was eventually held on 31st August 2012, well over a year after his death occurred and during which time there appeared a great reluctance to give any information or account for how he came to die. Kingsley was taken to a unit with the name of Mary Seacole, which itself associates the African Caribbean community as a whole with mental illness.

3.4 In the past ten years black women and men have been subject to brutal treatment from police officers in Wolverhampton, Bilston Street Police Station being the centre of focus. While some of their victims have no records of mental health problems officers have resorted to threats of sectioning telling them "you are mad". They have been taken to police cells or mental health institutions and held in custody.

3.5 So ten years on from a land mark report what has changed, especially for African Caribbean citizens. They remain vulnerable from a whole spectrum of inequality from individual attitudes to the institutional racism highlighted by the Stephen Lawrence enquiry. What the "cultural competence" recommended by the David Bennett report is remains unclear. Although widely referred to in the context of addressing mental health it requires a thorough going appraisal in order for it to become central to the training the report, and many others now recommend.

3.6 The NHS offers a guide for good practice in prisons. While it speaks of addressing inequality it confines itself to mentioning gender but avoids reference to the inequalities described above. The ratio of black people in jail proportionally was given as 7:1 in the Guardian, compared to 4:1 in the United States.

3.7 Evidence shows that black people are much more likely to be detained either in prison or secure units where they are likely to encounter heavy sedation.

4. The Asian community's concerns over access to appropriate services

4.1 While the focus of the last 10 years has been on the African Caribbean community, albeit with little, if anything, to show for it apart from continuing restraint and incarceration measures with further deaths in custody of those with mental heath problem and those assumed to have because of prevalent stereotyping and racist attitudes, members of the Asian community are asking if they too are being excluded from advances in treatment for mental health issues in the community. Lord Kamlesh Patel of the Mental Health act Commission speaks about a "hidden plague" affecting them and fear of a trend which is leading to them finding themselves in a comparable position to the African Caribbean community within 10 to 20 years.

"People of South Asian origin with mental health problems are missing out on treatment, the BBC has been told.
Experts warn it is contributing to the high suicide rate among Asian women.
The chairman of one NHS Trust says he blames "institutional racism" for the "lack of engagement" with the South Asian community.
And Lord Kamlesh Patel, of the Mental Health Act Commission, warned the "hidden plague" would grow if the problem was not tackled urgently."

 

4.2 In describing a failure to address need in the Asian community, itself diverse in respect of religious affiliation and variations between generations settled in the UK, attention is regularly given to social pathology or attributing blame to victims of failure to get support. Clearly features of differences such as family structure, values, beliefs and perceptions are important, but it can result in less attention being paid to ways in which traditional support mechanisms operate. This results in inappropriate intervention by clinicians making decisions without possessing the necessary cultural competence.

Case study
4.3 A Hindu man living in Birmingham suffered a brain haemorrhage in 1999 while in his early forties. He had a young family who were left deeply traumatised. He received remarkable care and treatment to bring him back to life, but an existence that required full time care. He had an uncle in India who had experienced a similar occurrence and in which case the family expected his wife to act as his main carer. Although widely spread his large extended family had similar expectations of his wife, faced with the daunting task of keeping his immediate family, a son of 11 and daughter of 19, together. He meanwhile was placed variously in highly successful rehabilitation followed by disastrous periods in homes totally unprepared and unsuited to his complex needs. Family and friends rallied together and devised a structural programme to stimulate him with the aim of allowing him as full a life as he could achieve.

4.4 Life for him in a care home quickly proved totally inappropriate with their inability to recognise his cultural, spiritual or social needs. Not that they were competent in other spheres of care in which they laid claim to expertise. The Primary Care Trust continued to proceed on a medical model of care based on the diagnosed medical condition of the patient and totally neglecting him as a human being. The possibility of him retaining his traditional position as head of his family was effectively removed, the family portrayed as a problem to the "care" they believed they needed to give.

4.5 The failure to comprehend cultural traditions leads to severe and potentially damaging consequences which can be very costly in terms of human suffering to the patient and their family but also financially for the health authority. The development of cultural competence is an essential component for a just, compassionate care system. Misconceived ideas of what this is are common, concentrating on known "facts" and possibly stereotypical ideas of other lifestyles. It is not just a matter of reading up about Hinduism, Sikhism, Islam or whatever, it is understanding how individuals relate to their wider family and how matters like mental illness are understood and the consequential decisions made, often by other family members, about necessary action. There is no solution other than for health professionals to work closely and co-operatively with family and/or community to be able to provide care which encompasses the range of need of the patient.

4.6 In more than a decade of care provision for their Hindu patient, the officers of the Primary Care Trust have failed to learn lessons from experience. In their retention of an outmoded medical model of care there has been a concentration on his medical condition coupled with a complete failure to account for cultural, spiritual and social requirements. This has led to frustration and ongoing battles with family members who have become vilified and labelled as problems who threaten their patient's well being and best interests.

4.7 From early on after a period of intensive support and rehabilitation this patient made an amazing recovery to the extent he regained ability to walk and speak. It was necessary for him to have 24/7 care and family and friends rallied round devising stimulation to aid a return to a life as fulfilling as possible. This was his wife's wish.

4.8 What the family were aware of and attempted to achieve owed much to their understanding of the situation. As husband and father he was regarded as head of the family and the change in his health and ability didn't change that. His carers however did not even imagine the possibility of other ideas based on their experience of life as Hindus, shared by an extended family spread across continents, all with their own beliefs and expectations within the shared culture. They had their own beliefs that religious acts would be beneficial and had high expectations that the family would continue their duty to a beloved family member. Unfortunately that was not so simple.

4.9 An initial period in institutions and care homes ranged from disastrous to a period of rehabilitation which once more regained progress damaged by life in alien institutions where their patient lost his identity. His behaviour deteriorated seriously during such periods. His immediate family continued to give support battling against uncomprehending bureaucracies. Their health suffered as a consequence although the care agencies failed to notice. Rather the family continued to be regarded as a source of irritation. This culminated in an attempt by the Primary Care Trust to get a protection order issued against the family. This failed when they couldn't produce evidence for the allegations made without any reference to the family.

4.10 Cultural competence, it is clear from this family's experience, has to do with an understanding of family dynamics, quite different in Asian culture to western tradition. Whereas in a western cultural model care staff routinely expect to be dealing with an autonomous individual in Asian families individuals have a place and role which cannot be overlooked and discarded. To vary this will ultimately be damaging and counterproductive. This understanding is chiefly located in the submerged bulk of the iceberg model. It is complex and requires carers to develop their understanding. This is only achieved by working closely with family and community.

4.11 A solution to the care in this case was to provide a bungalow with full time care. The family lived over a shop so the possibility of returning there was not an option. However the care company commissioned to provide the care were located in Telford. They were selected by the PCT and were not familiar with the needs and expectations of an Asian family. When problems arose the PCT regarded it as matter between the family and care company. The family wished to recreate family life as far as possible which would mean having family and friends round regularly. It soon became clear that the carers saw the bungalow as primarily a place of work, so what would have been a dining room became their office. Care staff brought in their own food, stored in in the family's fridge and used available utensils to prepare it. When beef products were brought in the family found it necessary to take action to say that could not be allowed. Furniture provided was dilapidated, and according to one of the relief staff an infection hazard, yet neither PCT nor the nurse in charge saw a problem. The family asked if they could bring in their own furniture, which was at first agreed. It was then pointed out to the family that if any items they brought in was the cause of an accident then they would be liable. They then had to pay for the furniture to be put in storage. The more the family tried to bring problems to the attention of the care provider, and when that failed the PCT, the more they were perceived as problematic.

4.12 Eventually the Primary Care Trust made a decision to change the care provider. They told the family it would be necessary for their patient to go into a care home for no longer than three months while they made necessary preparations. The family were unhappy with this but were given no choice. They wished to help with the transition and take their family member to his new temporary - they thought- home. The PCT disregarded their wishes and advice and a van driven by staff from the care home arrived and collected him. They disrespected both him and his daughter as they took him away from her treating without concern for either him or his family. The next time they saw him they were in for a shock. He was found to be inactive, confined to a wheel chair. He appeared uncared for with long hair and nails. Uncut toe nails meant he found it difficult to walk. He was wearing other people's clothes, having promised to label the new clothes the family supplied. A mixture of his and other clothes were found bundled in a heap in a wardrobe. The family found it hard to find the courage to visit. When they did they discovered a note on file warning staff about them and advising them to contact police if necessary. Although staff had acknowledged and apologised for their lack of care, the family remained the one regarded as at fault.

4.13 The family then raised their concerns with Birmingham Social Care and Health and so another meeting was called to consider protection issues this time at their request. There was still the belief that a return to the bungalow would happen, but it was agreed that another care home could be found in the meantime.

4.14. At the new care home family and friends attempted to help the new care providers understand their new resident's needs. However they were alarmed when they found information accompanying him had him classed as a Muslim and as having diabetes. It had been assumed that those responsible for his move would have monitored information on file. Surely records would accompany him from placement to placement. It seemed there was marked reluctance to listen to his family, but finally his religion changed to Hindu/Sikh whatever that means. While there were assurances that he had not been diagnosed with diabetes without the family's knowledge he was still tested for this on a visit to the dentist, apparently because it was still on the records.

4.15 It finally emerged that the decision to return home was changed by the PCT. In making their decision they failed to follow the Mental Capacity Act and consider the family's view on Best Interest. This means that those most likely to know what the patient's own views were likely to be on deciding where to live were ignored. It also means that a chance to demonstrate cultural competence was once again missed. It has been left for a court to make the final decision.

4.16 In her talk to a Sikh health conference in 2012, Kamel Chahal, Chartered Clinical Psychologist working in a London Health Authority, made the following points about menbers of the Asian community following Lord Patel's concerns in 3.1 above:

Women trapped in situations of domestic violence are well documented Women (ages 15-34) are 2-3 x suicides than British peers

Self-injurious behaviour is increasing in young women

High levels of alcohol use and dependence in men

Frequent presentations at GP surgeries with physical complaints

4.17 Those involved in delivering services to members of the Asian community need to be sensitive to the cultural perspectives and understanding of their patients. They have been identified as obstacles to individuals and families seeking help at a critical time. While these will vary between individuals and families western family patterns and traditions are vary from the characteristics of Asian families. As has been noted above it is important not to make assumptions, and there are likely to be variations between first, second and third generations settled in Britain.

4.18 Kamel Chahal refers to Rethink reports of work within the Sikh, Punjabi South Asian communities in Harrow, North West London

Research conducted by Rethink Mental Illness revealed six key findings;

1. Shame, fear and secrecy surround mental illness
2. The causes of mental illness are often misunderstood
3. The family can be both caring and isolating
4. Social pressure to conform
5. People with mental health problems are not valued
Marriage prospects can be damaged by mental illness
Extended family and wider community were felt by people with mental health problems to
have most impact on their lives.

 

The key learnings from the project are:
1. It's important to embrace the power of the community, its networks and local knowledge.
2. Pay attention to cultural dates of interest as hooks for PR and local activity.

 


5. IAPT - increasing access to psychological therapies. Source of equality or further discrimination?

5.1 One major advance in recent years is the understanding that the use of psychology can be effective in treatment of mental illness, which is as likely to stem from social factors as from physical illness. The development of such treatments is becoming a growing industry with universities like Chester setting up departments and publishing journals. I attended a conference to discuss the present state of affairs, but was concerned to see no contribution to the issue of diversity and a recognition of how cultural competence will be necessary for practitioners in the development of their skills. The question has to be asked whether this will intensify the situation where many will be denied a choice in their treatment on the basis of their ethnicity and culture. A current NHS document on IAPT acknowledges diversity and the requirement of cultural competence. Sections on this, while acknowledging complexity, are extremely brief.

5.2 Concern that much more needs to be done to ensure equal access across cultural groups appears to be shared by professional groups such as the Royal College of Paediatrics and Child Health

5.3 Kamel Chahal enumerated blocks within NHS services to Asian families accessing talking therapies:

Blocks within NHS Services:
Obstacles to Accessing Talking Therapies - Ethnic monitoring within psychology services shows:

"Less access to talking therapies (although often requested by communities in reports)
Less referrals from GP's & CMHT's
Less take-up of therapy when offered
Higher & earlier drop-out rates Issues related to cultural competence
Confidentiality fears - Major taboo to talk about problems outside home
Self-esteem built through different mechanisms - "we want" rather than "I want"
Value system and rules of living can be very much in conflict with "host" society
External & Internal Pressure to comply with cultural norms of: Impacted on by 1st,2nd, 3rd generational differences & ensuing cultural conflicts
Family structures & familial expectations - e.g. Marriage
Rules & subtleties in managing immediate and extended relationships
Folk-lore understanding of metal illness
Superstition, jinns, past lives, bad blood, not curable - passed on through families
Spirituality / Religious philosophy ignored."
Kamel Chahal 2012

 

6. The Voluntary Sector's role in supporting mental health needs of a diverse community

6.1 The "Talk to Us" project involved visits to some 40 voluntary organisations across the West Midlands. They typically involved enthusiastic and in many cases staff with long experience in working with sections of the community. These were usually those known to be at risk of failing to get appropriate, if any, help from the statutory sector. The organisations in the words of Ralph Hall of CSIP were "set up because of unmet need". Most expressed a wish to build their capacity to develop their services professionally to be able to deliver a high standard of care in partnership with health service professionals. Now in 2013 most are struggling to exist. They have to compete for contracts with large well-staffed organisations. While they have the knowledge and experience to deal with what matters to the communities they have sprung from and serve, they are often unable to contend with the bureaucratic requirements of complex contracts. This has become even more difficult in a period of transition for commissioning bodies as Primary Care Trusts (PCT's) end and Clinical Commissioning Groups (CCG's) evolve.

6.2 Professor Kamaldeep Bhui of Queen Mary College, University of London, argues the importance of the voluntary sector in addressing detention of those with mental health need. Professor Bhui has set up a Cultural Consultation Service (hear a podcast on the link provided) intended to address cultural factors in mental health services.

7. The Development of a Level 2 Syllabus to Improve Access to Appropriate Mental Health Services

7.1 While the first year report looked at key reports and recommendations following the David Bennett Report, 2003, the current report for year 2 considers the present position nationally, while drawing on case studies within the West Midlands where the SCYS Project is centred.

7.2 The headings above serve to signal key issues which seem essential for those serving a diverse community. The first thing to recognise is that mental health is a world wide problem which the World Health Organisation has described as "the silent epidemic" growing so that by 2020 it will be one of the largest and the most debilitating ailments facing human beings. There is no difference in the condition between diverse groups, but there is a difference of how it is understood according to cultural understanding and consequent approaches to help and support. On the one hand this can lead to a failure to take appropriate action to get help for self or other, on the other the views and lack of cultural understanding by health providers lead to a failure to provide appropriate services. This encompasses ignorance leading to misdiagnosis and willful racist attitudes. The David Bennett Report recommended thoroughgoing and continuous training in cultural competence and this has been retained through the previous government's Delivering Race Equality (DRE) agenda, backed by Count Me In statistics to present recommendations in "No Health Without Mental Health". While the DRE and Count Me in statistics have been archived they are by no means irrelevant. The decision to stop collecting is apparently because they repeat the same pattern, not because they have shown that matters are improving. Figures found elsewhere suggest that far from it detention of those with severe need are on the increase and need addressing. Professor Bhui states the importance of the voluntary sector in addressing this.

7.3 Outline of syllabus proposed based on sections discussed above.

Understanding of developments over last 10 years. The significance of the David "Rocky" Bennett report, it's recommendations. Setting up of the Delivering Race Equality agenda and collection of statistics annually in "Count Me In" reports. Appraisal of outcomes of legislation (see If only we were told Year 1 Report).

(ii)The current situation. Publication of Francis and Winterbourne View reports on care and recommendations for "compassionate care". what would this look like taking into account diverse needs of BME communities?

Cultural Competence. Iceberg model showing common understanding and failure to understand complexities of hidden (vastly greater) part required to address appropriate care provision. This is itself in need of developing and refining, particularly on the basis of experience of cases of care, including where there has been a significant lack of understanding of different expectations base on cultural differences in understanding of mental well being.

Advances in mental health treatment: IAPT and differential access. Factors preventing access and ways in which community engagement can help.

Working with statutory and voluntary agencies. Partnerships, discrimination and injutice, the voluntary sector and its role in the community.
Compassionate care - what this looks like for BME communities where cultural competence is put into practice