Mainstream services have “a lot to learn” from the poorly funded voluntary groups picking up the pieces. By Alex Leonards.
North Croydon, home of Crystal Palace Football Club, host to hopeful asylum seekers crammed into dreary buildings – a place where male life expectancy is nine years lower than a few miles south. A gamblers dream, where betting shops dominate street corners and abandoned offices stand by littered pavements.
In South Croydon, a short drive away, residents enjoy coffees in art cafés, visits to medieval churches, and strolls along the Happy Valley. The most populous London borough is divided by wealth and deprivation, as well as by its great expanse.
But Croydon is also divided by race. North Croydon is ethnically diverse, some of its areas have a majority Black and Minority Ethnic (BME) population, whereas the south is predominately white.
“In the North of Croydon you are less likely to live longer than those in the south,” says Croydon Community Development Worker (CDW) Risq Animasaun. “If you live in a deprived area there are other additional issues like overcrowding and less opportunities, and this contributes to poor mental health.”
If you live in a deprived area there are other additional issues like overcrowding
BME communities experience disproportionately high levels of unemployment, poor accommodation and bad health. It is unsurprising then, that BME people are more likely to be diagnosed with a mental illness than white people.
But what is startling, is that BME groups only make up 25 per cent of mental health service users. Despite having high levels of poor mental health, BME communities have less access to essential treatment, often due to a range of factors.
These may include a lack of information about available services, fears and stigmas about mental illness, the use of culturally inappropriate methods in mainstream services, and experiences of racism.
“Young black men tend to be perceived as dangerous, and the treatment they will receive is different to any other race. They’re more likely to be misdiagnosed, and less likely to receive talking therapy,” says Ms. Animasaun.
Young black men tend to be perceived as dangerous
Mind identifies racism, in both wider society and mental health care, as a stimulus for distrust in services, and a deterrent for BME people seeking help. Health professionals not recognising the effects of racism can also further the difficulty in accessing suitable care.
“People don’t understand the impact of racism on mental health, it’s important to get that message across,” says Ms. Animasaun. “Stephen Lawrence, David Bennett, Sean Rigg. These are young Black men that faced racial discrimination or mental health problems that lead to their deaths. Full stop. How come things haven’t changed?”
People don’t understand the impact of racism on mental health
The presence of these barriers mean that for many BME people suffering with a mental illness, their first experience of a service is in A&E, during some form of crisis, like a panic attack, psychotic episode or when suicidal.
“When they present late, what usually happens is the police get involved,” says Ms. Animasaun. “They get handcuffed, they’re brought in, sedated and kept in isolation, so it takes them longer to recover.” This type of detainment can be damaging, and often traumatic:
“The next time, they don’t want to tell anybody, because they’re terrified it’s going to happen again,” she says.
They get handcuffed, they’re brought in, sedated and kept in isolation
Mental health charity Mind say that higher levels of hospital admittance and home treatments in BME groups demonstrate that those who do manage to access crisis home care are “more unwell than the White group.”
In response to the death of David Bennett, a Black inpatient who died after being restrained by staff in a psychiatric unit, the Department of Health (DOH) produced a five year action plan that aimed to reduce the unequal levels of BME individuals being sectioned under the Mental Health Act.
Five years on, and the rates of compulsory detainment remain highest in Black groups. Health and Social Care Information Centre (HSCIC) statistics show that in 2013 just over 40 per cent of White British and Irish inpatients were detained under the act, in comparison to 70 per cent of black inpatients.
HSCIC research shows that the number of Black people who spent time in hospital between 2013-2014, as a percentage of those in contact with mental health services, is the highest of all ethnic groups.
In 2012, Ms. Animasaun co-wrote a report that found some BME patients had experienced poor care in mainstream mental health services in Croydon. The report, which assessed the experiences of patients, carers and staff at the South London and Maudsley NHS Foundation Trust, recorded complaints from some of the service users.
One service user said:
“I have experience of being aggressively handled by staff at other wards. When you are treated this way it stays with you and creates a lot of internal fear.”
The recovery of our economy does not improve the UK’s mental health. In fact, according to a World Health Organisation (WHO) report, the widening gap between rich and poor is a key driving force in increasing mental health problems. It is the poor who experience more stress, with limited resources, leaving the deprived “doubly victimised.”
Author of the report Dr. Lynne Friedli identifies inequality as a catalyst for mental illness:
“Neither the coalition government nor the current Conservative government have shown any meaningful recognition of inequality as a cause and consequence of mental health problems.”
She describes austerity as having a “devastating impact on mental health,” and believes budget cuts have seen those with mental health issues “over represented among those experiencing ‘sanctions.’” “The Bradley Commission,” published by the Centre for Mental Health (CMH), says that many BME groups “occupy particular positions of disadvantage in the UK.”
Neither the coalition government nor the current Conservative government have shown any meaningful recognition
The commission says that BME individuals are more likely to be diagnosed with a serious mental illness, like Schizophrenia, Bi-polar disorder or Psychosis. According to The Mental Health Foundation, African and Caribbean people are three to five times more likely to be diagnosed with schizophrenia than people from other ethnicities.
The DOH plans also aimed to reduce fears about mental health services in BME groups, and provide a more “culturally appropriate” and “balanced” range of treatments by 2010.
Ms. Animasaun works with mainstream organisations to help improve their communication and understanding of different BME groups.
The Croydon Clinical Commissioning Group has plans to fund the CDWs proposal to train staff in cultural competency at the SLAM NHS Foundation Trust. This will be an important project, as SLAM offers the largest range of mental health services in the UK, as well as serving four London Boroughs and over one million people.
“We’re making sure SLAM stays on target. Making sure they make those changes. It’s been very tough,” says Ms. Animasaun. “With organisations like that, they tend to drag their feet, because they’re used to certain things. Those changes might be difficult.”
Ms. Animasaun thinks that currently, voluntary services prove most effective in reaching out to BME people:
“Voluntary organisations are right on the pulse,” she says. “They know what’s happening, and a lot of the time when we ask people what services they go to, they mention voluntary organisations, not statutory organisations.”
Voluntary organisations are right on the pulse
A new report by The Race Equality Foundation, which is working alongside the DOH, found that voluntary services are more successful in providing appropriate care. However, voluntary and community based services are not in place to enrich mainstream NHS mental health services, but to “fill in the gaps” formed by their inadequacy.
One respondent from the report suggested that the gap in culturally appropriate care turned the traditional view of minority ethnic communities being “hard to reach” on its head. Suggesting instead that NHS services are difficult to access.
Samir Jeraj, co-author of the report says: “Too often the relationship between the voluntary sector and statutory services is that the voluntary sector supports those who either have issues accessing services, or services do not meet their needs.”
Voluntary organisations use a broad range of techniques to target BME communities, and provide the culturally appropriate services missing from NHS care. Alternative therapies such as yoga classes, acupuncture and creative arts are incorporated into many groups. The report found that many organisations felt “informal or holistic approaches might actually be more successful than formal therapy.”
The Croydon CDW Service supports a number of voluntary groups that use innovative and informal ways to engage with BME communities. Know My Mind, a community group made up of service users and carers, wrote So You Think I’m Crazy?, a play designed to raise awareness about mental illness.
It follows the journey of a young Black man with a mental illness, and has been performed across South London and at an international psychiatric convention in Birmingham.
“Its local people wanting to raise awareness about a local issue that could happen to anybody,” says Ms. Animasaun. “It’s important because there hasn’t been any kind of end in sight for young black men with mental health issues, it’s systemic.”
Local people wanting to raise awareness about a local issue
Although voluntary organisations are largely picking up the pieces for mainstream services, they are being hit hard by budget cuts. The report found there had been a “significant decline in support” for BME groups over the last five years. It identified the struggle to “balance limited funding” with the demand for services as one of the most difficult challenges for voluntary groups.
Like many community groups, Know My Mind struggled with a lack of funding:
“With the play, it was the determination of the people. When they had no means to fund their rehearsals, I got in contact with so many people, and someone in Croydon came back to me and said ‘we’ve got a space for them to rehearse, free of charge” says Ms. Animasaun. “This is Croydon pride.”
Ms. Animasaun is disappointed by the lack of funding for voluntary organisations:
“Voluntary groups are getting more pressure with less of the backing, it’s really unfortunate, but it happens all the time. When two go, another will replace it. But that’s not what you want, you want continuity. If something is good you should want it to continue.”
This is Croydon pride
In Croydon, drop-in centre and charity Healing Waters, which provided a space for service users and carers to discuss their needs, was closed this year. “The person who was running it was sometimes running it with her own money, because there wasn’t the means,” says Ms. Animasaun.
Mr. Jeraj of the Race Equality Foundation agrees that voluntary services should be better supported: “There is definitely an overwhelming case to provide a more stable and secure environment for voluntary groups.” He adds: “Continued austerity will put both public and voluntary sector organisations at risk.”
Amrita Kulkarin, a community development worker at Mind in Norfolk, recognises the need for active change across the country:
“Nationally, there needs to be more done to educate health and mental staff in cultural competency to tackle inequality and discrimination within the NHS,” she says.
Mind in Norfolk attempts to identify gaps in services, develop innovative approaches, and promote joint working, education and training. The programme acts as an access facilitator to services via community resources and by overcoming language and cultural barriers.
These methods aim to challenge what Mind describes as “different cultural frames of reference and understandings of mental health,” which leave many people considering traditional methods irrelevant and unhelpful. Mental health services “may not recognise the mental health element of a person’s illness” and in turn fail to refer a patient to appropriate specialist care.
Ms. Kulkarin believes that steps towards providing a more culturally appropriate mental health service are not just favourable but necessary:
“Understanding individual and a community’s cultural beliefs about mental illness is essential for the implementation of effective approaches to mental health care.”
Ms. Animasaun too recognises the need for cultural understanding in mainstream services:
“In some languages they don’t even have a word for depression,” she says. “For a lot of people they will say “my heart is heavy,” “my head hurts,” or “I haven’t been sleeping.” If you’re not culturally aware as a medical professional you will miss some of those cultural cues.” This is why it is so important for mainstream NHS services to learn from culturally aware voluntary organisations.
However the Race Equality Foundation report found that there is often a lack of recognition for the hard work being done by voluntary organisations. One respondent of the report said “a lack of awareness about service demand or the specific needs of service users” by mainstream services, resulted in “these people being hidden, and the work done to support them hidden too.”
Ms. Animasaun argues that voluntary and community groups are not taken seriously by mainstream bodies:
“Voluntary organisations are seen as not the real deal, as a vocation – like these are do-gooders, they’ll do it anyway. And also they think they’re not professional, and that’s a big mistake people make. Statutory services have got a lot to learn from these groups,” she says. ““I don’t think they get the recognition that they truly deserve, I know that in Croydon there are some amazing groups and they do incredible work.”
Mr. Jeraj of the Race Equality Foundation looks to the Equality Delivery System (EDS), which has been in place since 2011 to help improve services for local communities, for change. “Earlier this year, the NHS made EDS a requirement for all NHS organisations,” he says. “This should mean that they are required to reduce health inequalities and promote equality.”
But whether these plans are able to infiltrate the stubborn traditions of the mental health system, and provide equal care, is yet to be seen. Whilst services continue to fail BME communities, within the short distance of two ends of a borough, a vast gap between the silently suffering, and the comfort of the wealthy, remains.
If you have been affected by any of these issues, the following organisations can help:
Call The Samaritans on 08457 90 90 90 (24 hour helpline)
Call Mind on 0300 123 3393 (Mon-Fri, 9-6pm)