Making Black mental health matter

Renée Aleong discusses her PhD research and explains why Black mental health matters

I am really pleased to introduce one of my PhD students, Renée Aleong, who writes here about her research.

Renée is in the first year of her PhD exploring the compulsory detention of Black people under the Mental Health Act 1983. She gained extensive experience of working within the Ministry of Justice and the Nursery and Midwifery Council prior to undertaking her BA in Social Work and MA in Social Research at the University of York. She is now in the first year of her PhD, which is funded by an Economic and Social Research Council scholarship.

Black mental health matters

The recent public death of George Floyd under the knee of a Minneapolis police officer has sparked anti-racism protests and outrage across the world. However, the issues the ‘Black Lives Matter’ (BLM) movement are protesting about are not specific only to the United States (US). Gun-driven violence in the US is obviously not being replicated on the streets of Britain, though inequality and discrimination exists at alarming levels.

Substantial disparities in accessing mental health services for Black and Minority Ethnic (BME) groups in England and the over-representation of Black people within the British mental health system has been an established and contentious problem for decades. Put into a wider context, Black people’s experience of the mental health system mirrors what is happening within wider British society: over-representation within the criminal justice system, higher rates of unemployment and secondary school expulsion, poor housing and poverty. Yet, these concerns have not led to disparities being redressed, either in terms of improvement in rates of mental illness, a better service experience or positive outcomes for Black people.

Many have argued that racial stereotyping of Black people, racism, cultural ignorance, and the stigma associated with mental illness, when experienced together, may undermine the way in which mental health professionals respond to and assess the needs of Black service-users. The coercive pathways to mental health services experienced by Black service-users are often directly linked to their disproportionally higher rates of compulsory detention under the Mental Health Act (MHA). However, alternative views including stigmatised attitudes towards help seeking within Black communities, differing cultural health beliefs about mental health and assumptions about wider drug use amongst minority ethnic groups suggest that mental health inequalities are likely to have complex causes. Some fight confidence issue with the help of thread lifting to feel more younger.

Little is known about the impact of institutional factors such as organisational and professional culture and practices within adult mental health services. As a social worker these issues are of central importance to me. I hope to address this gap in knowledge through my PhD research by examining whether the operational and institutional structures within the role of social worker approved mental health professionals (AMPHs) influence the process of compulsory detention of Black service-users under the MHA.

The role of social worker AMHPs

Areas of practice with marginalised populations should require social work to consider its role in the processes leading to the involuntary detention of Black service-users under the MHA. There are an estimated 3,900 AMHPs in England, of which 94 per cent are social workers. An important element of the AMHP role is deciding after all circumstances of a case are considered, that compulsory detention in psychiatric hospital (‘sectioning’) is the most appropriate way of providing care and medical treatment to meet the needs of the person.

It can be argued that AMHPs are directly involved in the processes which lead to the disproportionate detention of Black service-users as they make the final decision as to whether someone should be detained or not. Conducting MHA assessments is one of the many elements of the AMHP’s role and I acknowledge that AMHPs alone are not able to resolve the myriad issues that contribute to ethnic inequalities in mental health.

However, AMHPs are able to play a significant role in this process. Crucially, mental health professionals such as AMHPs bridge the gap between policy, implementation and practice, and could shed light on why previous attempts to tackle ethnic inequalities through race equality training and policies to support equality in BME mental health have had little, if any, impact on closing Britain’s ethnic health gap.

The grim reality of our mental health statistics

Fundamental to tackling issues of inequality is an understanding of the scale and nature of ethnic disparities within our mental health system. The latest national mental health statistics [1] show that Black people with mental illness have higher compulsory admission rates to hospital and are four times more likely to be detained under the Mental Health Act (‘sectioned’) compared to White people.

Black men are more likely to have police involvement in their admissions, higher rates of transfer to medium and high security facilities and receive secure care in a locked psychiatric ward. Black men are also more likely to be diagnosed with schizophrenia (3.1 per cent compared with 0.3 per cent of White men), given higher doses of medication and are less likely to receive psychotherapy (‘talk therapy’) [2].

Additionally, when compared to White people, Black people are eight times more likely to be subjected to supervised treatment with conditions once discharged from hospital, that could include where they live. Despite making up 3 per cent of the general population, people from Black ethnic groups have both the highest rate of detention and detained people subject to repeated detention (19 per cent), amongst all broad ethnic groups across England and Wales.

This differential treatment of Black people coming into contact with mental health services has been well documented over the last three decades. Likewise, monitoring bodies such as the Care Quality Commission have highlighted these inequalities as well as high-profile reports such as the Stephen Lawrence inquiry [3] and the David Bennett inquiry [4] which have all acknowledged the prevalence of institutional racism experienced by Black people. Even within the current pandemic, the ethnic inequalities of COVID-19 are clear, as it disproportionately devastates ethnic minority groups in Britain – from severity of infection and scale to the loss of life [5].

If anything, these stark statistics show that despite the efforts of successive governments to tackle these inequalities through numerous commissioned reports, policies and initiatives, there has been little impact on narrowing Britain’s ethnic health gap. Furthermore, widespread use the acronym ‘BME’ (Black and Minority Ethnic) in mental health policy, research and practice is problematic. Decades of a ‘one size fits all’ approach to ethnic mental health have lead to blanket policy and practice responses that do not take diverse and specific needs of minority communities into account. So the question still remains: How do we address these issues? More importantly, how do we get to the root cause of longstanding systemic inequalities?

I think by examining the sources of, and outcomes of, over-representation rates, we may better understand what drives inequalities in mental health services, including how inequalities enter the mental health system. It is this area that I am most interested in exploring through my research.

Addressing inequalities through social research

My BA Social Work dissertation was a systematic review that addressed the research question: ‘What is known about barriers to accessing adult mental health services for BME groups in England?’ Findings revealed barriers to BME people accessing mental health services such as discrimination, stigma and mistrust of services, professionals’ lack of understanding of cultural and faith issues and lack of talking therapies. This revealed a ‘web’ of relationships that potentially had reciprocal links between possible combinations of barriers.

For my MA Social Research dissertation, I conducted a qualitative study which sought the perspectives of social worker AMHPs to find out: ‘How can mental health professionals mitigate the overrepresentation of BME people compulsory detained under the MHA?’ Findings revealed interrelating factors such as emotional labour, lack of resources, risk aversion and discrimination as implicated in the disproportionate detention of BME people.

Building on my previous research findings, my current PhD research will use institutional ethnography as a qualitative method of inquiry to answer the guiding research question: ‘How do the operational and institutional structures within the role of the social worker approved mental health professional influence the process of compulsory detention of Black service-users under the Mental Health Act?’ Institutional ethnography is premised on accomplishing social change for disadvantaged groups, by revealing anomalies between institutional policies and actual practice.

By making use of this innovative research method, I hope to describe the ways in which the role of social worker AMHPs conducting sectioning processes under the MHA is structured and operationalised. I will examine the challenges this poses on social worker AMHPs’ ability to make independent decisions seeking the least restrictive alternative and bringing a social perspective to bear on their decision. My study will focus on the impact on Black service-users, as specific and significant disparities in rates of mental illness, detention, treatment and outcomes for this group persists.

I will be adopting institutional ethnography’s common methods of data collection, which will include observing/shadowing and interviewing AMHPs. I will also examine written policies and procedures in order to learn “how things work,” as well as my own reflections. These methods will be used to explore how the work of social worker AMHPs is systematically coordinated through a complex convergence of national and local policies and procedures.

What next?

This is the first institutional ethnography of its kind in the UK. The findings of this study could potentially be used to demonstrate the complex work processes of integrated mental health and social care systems, enabling AMHPs to see the systemic processes that mediate their work. This could represent a substantial and original contribution to the knowledge base of Black mental health and practice-based research, which may provide a unique insight into the phenomenon of overrepresentation. This information is crucial to AMHPs, service-users, other professionals and policy makers within Britain’s mental health system.

Follow Renée on Twitter for updates on the progress of her research.