RACISM, DISCRIMINATION AND MENTAL HEALTH

SS6308: Mental Health and Disability

MARCH 26, 2014 MARTA SANTANA GUERRA 110379615@ucc.umail.ie

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CONTENTS Introduction ....................................................................................................................................................................... 2

Association between racism, discrimination and mental health: The evidence ...................................................... 2

Other associations between health and racism ...................................................................................................... 4

Explanatory models of illness .................................................................................................................................... 5

Why is racism, discrimination an Irish psychiatric practice preoccupation? .......................................................... 6

Potential access barriers of mental health services among ethnic minorities......................................................... 9

The National Intercultural Health Strategy .............................................................................................................. 9

An international example .............................................................................................................................................. 12

Conclusion .................................................................................................................................................................... 14

Bibliography ......................................................................................................................................................................... 15

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RACISM, DISCRIMINATION AND MENTAL HEALTH

Introduction

In this paper the relationships found between racism, discrimination and mental health of ethnic minorities

will be examined. The initial themes discussed in the paper will range between the impacts of perceived

discrimination and racism on the mental health outcomes of ethnic minorities; the psychiatric practice

available to treat ethnic minority individuals, the inequalities of access, diagnosis, admissions into acute

centres and treatments. In addition the paper hopes to shed light on two further points. One being, to

clearly express why the impacts of racism and discrimination on ethnic minority well-being should be

taken into consideration by Irish psychiatric practices and policy makers; and two, to provide a summary of

methods to bridge the gaps in Irish psychiatry practices, health policy and inequalities of minority’s

diagnosis, and access to treatment. The paper seeks to answer three questions, which will outline the

format of the report. The answer to these questions; the author believes will provide the reader with a

holistic comprehension on the importance of the above issues for the Irish context.

ASSOCIATION BETWEEN RACISM, DISCRIMINATION AND MENTAL HEALTH: THE EVIDENCE The author has selected studies which she believes will provide the reader with an understanding in regard

to the relation between mental health outcomes and perceptions and experiences of racism and

discrimination among ethnic minorities and their respective members. Race and racism was first

introduced into psychiatry practice in the UK in 1975, where the new Transcultural Psychiatry Society

was set up and became a forum for psychiatrists and anthropologists interested in the subject of race and

culture and the impact of racism on ethnic minorities which was to “be recognised as the primary problem

which the society [aimed] to correct”. Moreover in 1984 the Transcultural Psychiatry Society reformed

its aims to promote equality of mental health irrespective of race, gender, or culture, and was committed to

having a multiracial, multicultural, and multidisciplinary involvement with society it became committed to

“revealing” the racism within psychiatry. Several members of the society took a critical attitude to British

cultural psychiatry revealing that ethnic minority members were being targeted with preferential

psychosis symptomology, and disparate large numbers of individuals being given diagnosis of

schizophrenia in particular ‘Black’ patients, possible misdiagnosis due to culturally unadapted

psychometric scales and inventories and higher rates of compulsory detention under sections of the Mental

Health Act. (See, (Bebbington, 1994); (Cole, 1995); (Dunn, 1990); (Littlewood, 1992)

In a study by Fearon et al, 2006 (Fearon P. &., 2006) (Fearon P. K., 2006) revealed how members of the

African Caribbean population in the UK have consistently been identified as three to twelve times more

likely to be diagnosed with schizophrenia than White British individuals. In a study involving 568

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individuals the authors concluded that ethnic minority groups had an increased risk for all psychotic

illnesses but and Black Africans in particular appeared to be at higher risk of both schizophrenia and mania

diagnosis. Fearson et al, 2006 suggested two causalities to the findings (a) that common risk factors occur

in both the lives of African-Caribbean’s and Black Africans or that these risk factors are specifically

prevalent in these groups, and that (b) these risk factors increased risk for schizophrenia and mania in

these two groups. In a similar study by Coid et al, 2008 in his study of prevalence of psychosis in three

boroughs of East London the authors concluded that both non-affective and affective psychoses were

observed for all of the Black and minority ethnic subgroups (Asians) compared with White British

individuals. (Coid, 2008) Some authors have argued that these common risk factors among ethnic

minorities diagnosis of psychosis can be directly related to discrimination or perceived discrimination and

racist experiences. (Cantor-Graae, 2005) (Veling, 2008) (Fernando S. (., 2010)

N. Kreiger, (Krieger, 1999)conducted a literature review on discrimination and general health evidence,

identifying 15 studies, and in 2000 (Williams DR W.-M. R., 2000) a review of studies related specifically to

discrimination and mental health identified 13 studies. In 2003 Williams and colleagues conducted yet

another review of available empirical evidence from population-based studies on the association between

(perceptions) of racial/ethnic discrimination and health, they identified 53 studies, 24 of which were

published from 2000 onwards suggesting an increase interest in the matter. Williams et al, 2003 research

study revealed that discrimination is associated with multiple indicators of poorer physical and, especially,

mental health among minorities; they identified mental health criteria to be the most studied research topic

in association with (perceived) ethnic/racial discrimination. Of 53 papers reviewed, 32 included a measure

of mental health, the majority of the 32 studies involved (25) examined for psychological distress and 20 iof

those reported a positive correlation between discrimination and distress after controlling for

demographic/socioeconomic factors, 3 iireported the presence of a positive association but only under

certain conditions; 2iii of the studies reported no association. Six studies examined (perceived)

discrimination and psychological well-being indicators (e.g. happiness, life satisfaction and self-esteem) all

of which are useful buffers against stressful circumstances; 5iv of the 6 studies reported a positive

association with discrimination. Studies which examined the relationship between (perceived) racial/

ethnic discrimination and a diagnosis of major depression, were also identified by Williams et al, and 4v out

of 3 research papers revealed a positive association between perceived discrimination and depression.

Other studies focusing on common mental health disorders examined the association with generalized

anxiety disorder, initiation of substance use, psychosis, and anger, and similar to the results from other

studies they all found a positive association with discrimination. It is worth bringing to the reader’s

attention that none of the mental health studies referenced in Williams et al, 2003 systematic review found

a negative association. (D. Williams, 2003)

One hundred ten studies in a meta- analysis carried by Pascoe and Richman 2009 presented sufficient data

on the relationship between perceived discrimination and mental health, the mental health

symptomatology outcomes included for a variety of mental illnesses (e.g., depressive symptoms, anxiety

symptoms, posttraumatic stress symptoms, and indicators of psychosis or paranoia) and psychological

distress; also 448 (90%) studies in the meta-analysis found that higher levels of perceived discrimination

were related to more negative mental health status, with 345 (69%) of the 500 analyses reaching

significance. (Richman, 2009)

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However the extent to which exposure to (perceived) discrimination leads to increased risk of illness

mental and physical and the conditions under which this might occur (neighbourhood, workplace, school

etc.), or the mechanisms and processes (e.g. duration of exposure, coping strategies [avoidant or active])

that might be involved is yet unknown. In addition to gaps in knowledge it is noteworthy that there is

considerable critique on the studies variation in methodological quality and inadequate mental health and

discrimination scale suitability, with the majority of the studies having at least 1 serious methodological

limitation. (D. Williams, 2003)

OTHER ASSOCIATIONS BETWEEN HEALTH AND RACISM In the last decades psychosis has stolen the spot light of mental health research, particularly in the field of

cross-cultural psychiatry/ psychology, however common mental disorders such as depression and anxiety

have been gaining attention from researchers lately. Weich et al, 2004 compared the prevalence of

common mental disorders among a representative sample of White English, Irish, Black Caribbean,

Bangladeshi, Indian, and Pakistani individuals living in the UK using a standardized clinical interview, the

results revealed that middle-aged Irish and Pakistani men, and older Indian and Pakistani women,

demonstrated significantly higher rates of CMD than their White English counterparts. (Weich, 2004)

A year later, Karlsen et al, 2005 linked the relationship between risk of psychosis and common mental

disorders to experiences of racism among ethnic minority groups in England. Overall the results revealed

that experience of racism and that perceiving racism from the host society was found to have independent

effects on the increased risk of common mental disorders such as anxiety and depression and psychosis,

after controlling for the effects of gender, age, and socioeconomic status. (Karlsen, 2005)

Another significant focus of research has been on ethnicity and self-harm. Cooper et al. (2012) as part of

the Manchester Self-Harm Project examined the risk factors for repeated self-harm in South Asian and

Black people in comparison to Whites. Risk factors for repetition were similar across all three groups, but

excess was seen only in Black people and South Asian people presenting with mental health symptoms and

reporting alcohol misuse. As suggested by the stress coping model, substance use often serves as a means

to reduce the negative effects of perceived discrimination in a study by Clark 2014, examining the

relationship of perceived discrimination and depressive symptoms with lifetime and recent substance use

among African American and African Caribbean young adults, the results revealed that depressive

symptoms fully mediated the relationship between perceived discrimination and recent substance abuse but

could not account for lifetime substance abuse. (Clark, 2014) (Cooper J., 2012,)

It is unknown yet whether consistent exposure to perceived racial/ ethnic discrimination augments the

impact of the stressor or leads to patterns of coping attitudes and practices, such as alcohol misuse and

smoking so that the effect of perceived discrimination is minimized or the effect of the stressor. Williams et

al, 2003 recommended that research on discrimination needs to take into consideration the joint effects of

multiple types of stressors which may magnify other non-race-related stressors, e.g. being bullied in work

because of one’s race (acute discrimination) can trigger psychological distress such as depression, which in

turn can lead to reluctance to join the work force creating financial hardship (chronic stressor). (D.

Williams, 2003)

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Research should also take into consideration that perceptions of racial/ ethnic discrimination might

adversely interchange from affecting an individual’s mental health status to influencing one’s physical

health primarily due to negative emotional states such as low self-worth and low self-esteem, which in turn

can have direct effects on biological factors (e.g. genetic precondition to depression) and patterns of

behaviour (e.g. alcohol misuse, binge eating) that exacerbate the development of disease. Although the

findings of association between perceived discrimination and physical health are complex, most studies

provide a clear contribution to their connectedness. Williams et al, 2003 identified 10 studies which

examined self-report indicators of health status; 6vi of these studies revealed a positive relationship with

perceived discrimination, 2vii reported a positive association only under some conditions. Eleven studies

examined the association between discrimination and hypertension among minorities; revealing positive

association between discrimination and blood pressure in 3viii studies and in 5 studies, the effect was

dependent on other variables (coping style sex or social class or ethnicity). Threeix studies revealed a

positive correlation between perceived discrimination and cigarette smoking, and 2x other articles reported

similar associations for alcohol misuse. (D. Williams, 2003)

EXPLANATORY MODELS OF ILLNESS One can question whether the findings of higher prevalence’s of schizophrenia in ethnic minority groups

are a reflection of common risk factors which make for the exceptionally high incidence rate of

schizophrenia and other psychoses in immigrant and ethnic minority groups or perhaps due to the limited

versions of culture adapted assessment tests used by psychiatrists. Furthermore we may also question the

validity of taking schizophrenia as a cultural universal disorder; while some researcher’s such as (Fabrega,

1989) have emphasised that the disorder is based on a Western conception of its symptomology which may

differ from non- Western cultures or in fact, non-existent. Niyati Evers has produced a research paper on

shamanism and schizophrenia, including an interview with Botswana Sangoma (spirit healer) Colin

Campbell in which Collin explains:

“There is no such thing in African culture. What we see, is that a person is behaving in a certain way. A

million things could be causing that behaviour. It could be because of many different types of spirits;

nature spirits, ancestral spirits, etc.” (Evers, 2008)

In Western cultures mental illness is often explained in biological/psychosocial terms however in non-

Western cultures understandings of mental illness is often drawn upon spiritual traditions such as

shamanist rituals. Dein, Alexander, and Napier (Dein S., 2008) carried a study which sought to examine

understandings of associations between and health and misfortune among Bangladeshis, in particularly

with respect to the role of jinn spirits (supernatural creatures in Arab and Islamic folklore teachings that

occupy a parallel world to that of human kind). The authors found that patients will often appeal to jinn

explanations of poor health particularly at times of unexplained acute stress and other physical symptoms.

Spirit possession and witchcraft (voodoo) were frequent explanations for their illness and so the use of

traditional healers was frequent other than western doctor diagnosis and treatment. Unlike western

diagnosis and treatment “the process that is followed is a combination of divination, ritual, enactment and

plant medications […] if a person suffers from a possessing spirit, there is again a different scenario. In

that case, the person needs to develop a relationship with the possessing spirit or go through an exorcism.”

(Evers, 2008) (Dein, 2010)

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In certain cultures (e.g. South Africa) an individual who ‘suffers’ or develops a schizophrenic disorder is

viewed as an visionary healer who is being called into or initiated into expansion of consciousness to

include beings of other planes of existence, therefore a valued individual in that community. In the

shamanic view schizoid like symptomology such hearing voices is seen as “the birth of a healer”. (Gaddis,

2010)

Jason Gaddis reprinted on his blog an extract from Stephanie Marohns interview with Malidoma Some, a

West African Shaman. Dr. Somé’s statements give the reader some insight into the perception of non-

Western views of mental health treatments in the Western world: “So this is how the healers who are

attempting to be born are treated in this culture. What a loss! What a loss that a person who is finally

being aligned with a power from the other world is just being wasted.” This perception clearly depicts the

importance of ‘survivor’ led research and training in the area of mental health. (Gaddis, 2010)

WHY IS RACISM, DISCRIMINATION AN IRISH PSYCHIATRIC PRACTICE PREOCCUPATION? The last two decades have seen in Ireland the significant development and increased interest in

discrimination/ racism and equality studies in. However, while expectations of a fair society for all has

become an increasingly attractive ideal most nations strive to live up to; Ireland still suffers from short

comings, particularly in relation to its anti-discrimination legislative framework. Also relatively little is

known of the true nature and actual extent of discrimination among ethnic and immigrant minorities in

Ireland, in part because discriminatory behaviour is rarely observed directly and measures of

subjective/perceived discrimination evidence may be subject to bias, often resulting in criticism by

academies, policy makers and politicians another common problem being that of under reporting. (Helen

Russell F. M., 2010)

Figures reveal that the immigrant share of Ireland’s population doubled in just under a decade, growing

from 6 per cent in 2002 to 12 per cent in 2011 (Monitoring Migrant Integration in Ireland, ERSI 2013).

The European Social Survey, used to examine attitudes of the Irish population towards immigrants and

immigration in the period 2002-2010 reveal that positive attitudes to the economic and cultural

contribution immigrants make to Ireland was more prevalent from 2002-2006 during the Celtic Tiger

boom years, however the trend becomes more negative between 2008 and 2010, when the economic

recession hit Ireland. Also openness to immigration (willingness to accept immigrants of the same

race/ethnicity, a different race/ethnicity and immigrants from poorer countries outside Europe) was

higher in between 2002-2006, decreasing again from 2008 onwards. (Frances McGinnity, 2012)There has

been a noticeable link between economic recession in Ireland and increasing rates of racist attitudes

towards ethnic minorities and immigrants, even without the use of insightful data from social research

there is an increasing widespread perception amongst the public that racism and associated offences are on

the rise. “A study conducted by the Migrant Rights Centre Ireland (MRCI) in 2010 stated, with reference

to the second Lisbon Treaty referendum in 2009 that: ‘Growing hostility towards migrants is a worrying

development in the current recession. The role of the tabloid media and some right wing anti-Lisbon

Treaty groupings circulating anti-migrant and racist propaganda was particularly evident in the lead up to

the Irish vote on the EU Treaty.’ (NASC, 2012)

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Figure 1. % of those who did not report incidents of discrimination and the reasons why (EUMIDIS 08).

In support of this argument, integrated threat theory (Stephan, 2000)emphasises the link between

perceived threat and intergroup conflict. In times of national economic difficulty realistic threat

perceptions (threats to the political, welfare & economic power relations) have a strong relationship to

opposition to immigration; facilitating discriminatory attitudes towards immigrants and ethnic minorities.

(Pereira, 2010)

On the issue of discrimination and racism rates in Ireland, although anti-discrimination is seen as a major

indicator area for integration effectiveness, Ireland’s anti-discrimination progress has severely deteriorated

since 2010. Referring to MIPEX (http://www.mipex.eu/) reports; between 2007 and 2010 Ireland’s anti-

discrimination protection had not improved. Racism and discrimination prevalence rates in Ireland have

continuously been relatively high for its population ratio. 55% of participants surveyed in the NASC

Survey 2012 (‘Stop the Silence: A Snapshot of Racism in Cork) believe racism is an issue in Cork. The

figures increased to 62.3% when including the responses of African participants. The same rate is revealed

in the EU MIDIS 2008 survey on discrimination rates among EU member States, which show that general

discrimination experiences between 2007 and 2008 prevailed at 54% for Sub-Saharan Africans and at 26%

for CEE’s (Central Eastern Europeans) living in Ireland.

Although the above figures are quite relevant they may not encompass the full extent of discriminatory

experiences in Ireland due to the issue of under-reporting of racist and discriminatory experiences. Even

though up to 54% of South Saharan Africans experienced racism in 2007-2008 (EU MIDIS 2008) 58% felt

that nothing would happen if they had reported. The local NASC Survey 2012 revealed similar results.

(See figures 1 & 2)

The two available racism reporting mechanisms have endured continuous criticisms on their suitability to

record incidents of the type.

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Figure 2. % of those who did not report incidents of discrimination and the reasons why (NA SC A snapshot of racism in Cork 2012).

In recent months there has been a noticeable pattern of media reporting on racism and discrimination

themes. The most frequent headlines state that racism and discrimination has seen an almost exponential

rise in recent months.

“Warning of rise in racism among Irish children” December 30, 2013 the Irish Examiner

“Huge increase in racist behaviour in Ireland” 07 DECEMBER 2013 The independent

“Irish urged to take stand against rise in racism” 10 DECEMBER 2013 The independent

“‘Alarming increase’ in racist incidents, says immigrant body” 07 DECEMBER 2013 the Irish Times

“Racism rising at an ‘alarming rate’ in Ireland” Jun 26, 2013 The Journal.ie

The modelled results from the ‘The Experience of Discrimination in Ireland. Analysis of the QNHS

Equality Module’ 2008 provide information on the risk of the experience of discrimination among all

immigrant and ethnic groups in Ireland. The model reveals that individuals of Black African ethnicity are a

more vulnerable group than ‘White’ immigrants. 40% of Black respondents revealed experiences of raw

discrimination in all areas of life compared to white respondents (12%). Model results show that visible

minority group members (e.g. Black individuals) are almost twice as likely to perceive discrimination as

their ‘White’ immigrant counterparts (1.5 times more likely to perceive discrimination). (Helen Russell E.

Q., 2008)

It is clear from the studies mentioned in previous chapters that perceived discrimination and experiences of

racism, create stressful imbalances in the lives of its victims and can take an adverse toll on their physical

and mental health directly and indirectly. We have also established that experiences of discrimination at an

interpersonal and institutional level are prominent among the ethic and immigrant minorities residing in

the Republic. In the next chapter we will examine how well equipped the Irish mental health care are to

pg. 9

cater for the mental health needs of Ireland diverse groups. Regarding service use, discrimination can

create barriers to access of mental health services among minority groups, including lack of information

about the services, economic constraints, cultural incompatibility, and communication problems. In a

national survey developed by the ERSI in relation to experiences of institutional discrimination among

1089 immigrant and ethnic minority members around 14 per cent of those with contact with Irish health

services reported bad treatment. Black Africans reported the highest proportion of bad treatment, many

individuals reporting it occurring more than once. East Europeans also reported high levels of bad

treatment (18 %). Again reported poor treatment from healthcare services was higher among asylum

seekers (25%). (ERSI, 2006)

POTENTIAL ACCESS BARRIERS OF MENTAL HEALTH SERVICES AMONG ETHNIC MINORITIES Finally, it is important to point out that many members of ethnic minority communities experience a

variety of disadvantages when they access, statutory mental health services. International efforts have

been made to resolve these issues by developing mental health projects both within statutory services and

in the NGO sector. Fernando (2005) has provided an overview of the voluntary sector services in the UK

designed to cater for the health needs of ethnic minorities. In the UK as in the Republic of Ireland

statutory mental health services have continued to use a model that is based on traditional western

European psychiatry.

In the last three decades many counselling and psychotherapy services have been developed by what is

generally called the “Black voluntary sector” to cater for the mental health needs of ethnic minorities.

Taking as an example projects developed in the UK, include: Ipamo, developed in the early 1990s, several

black activists interested in mental health issues conceptualized and obtained funding for what is

essentially an alternative psychiatric centre for black people who would otherwise be admitted to a generic

psychiatric unit. The therapeutic approach combines traditional (western) approaches to mental health

with ideas from black social and political movements, notions of spirituality using input from local black

churches and an approach to counselling, called ‘black therapy. Other voluntary practice developments are

Nafsyat in London set up in 1983 which provides psychotherapy for African/ Caribbean black and ethnic

minority individuals, the Qualb Centre in London which provides counselling and complementary

therapies for Asian people and the Nile Centre in London, offering crisis support for Afro-Caribbean and

African people with mental health problems. (Fernando S. , 2005)

In the context of Ireland access barriers to mental and other health care services was mostly likely to

relate to socioeconomic status. In the next chapter we will discuss some of the access barriers to quality

mental health and other health care services and practices among ethnic minorities residing the Republic

of Ireland. The chapter focuses on the evidence gathered from the consultation meetings carried during

developmental stage of the NIHS (National Intercultural Health Strategy) and of CAIDRE the ethnic

minority forum.

The National Intercultural Health Strategy The NIHS report is the outcome of national, regional and local consultation events with minority ethnic

organisations, community based and advocacy organisations, individuals, migrant workers, refugees,

asylum seekers and Travellers that were held to inform the HSE on the development of an Intercultural

pg. 10

Health Strategy. One of the developments that arose from the NIHS was the Ethnic Minority Health

Forum- CAIRDE, the forum has a collective approach which brings together minority ethnic groups

across the Republic of Ireland to identify and discuss issues and concerns affecting the health of minority

communities.

There was a wide diversity of perspectives and experiences provided during the consultations by all parties

involved, however the themes most highlighted were the combination of low incomes, social isolation and

poverty experienced by many minority ethnic groups, which is disproportionate to that of the majority

population. In a written submission the Combat Poverty Agency stated that “…the strong relationship

between poverty and health is well established. Ethnic minorities who are most likely to experience poorer

health are those who are living in poverty. These are Travellers, asylum seekers, and some refugees and

migrant workers”.

The latter were emphasized as being the most vulnerable groups therefore requiring special consideration,

the barriers most often associated with the following groups were “in accessing services e.g. medical card

eligibility, poor accommodation and ill health, isolation, experiences of racism & discriminatory, illiteracy ,

lack of appropriate information, communication/language barriers and culturally incompatibility practices.

(Pillinger, 2007)

The main barriers to health service identified and discussed by the consultants were:

1. Information and communications barriers: cultural contexts and languages, including an

understanding of how the health system works. Poor signage in other languages or accessible

formats in hospitals and health centres. Lack of translated materials and provision of interpretation

services. Poor quality translation services e.g. family members providing interpretation,

interpreters without training.

2. Awareness barriers of staff providing health services, misunderstanding the needs, expectations and

cultural backgrounds of service users.

3. Participation barriers: inclusion and involvement of minority ethnic service users and communities

in the ongoing provision and development of health services, and in addressing health inequalities

and improving health outcomes.

4. Cultural barriers in understanding how the health systems can take account of the diversity of faith

systems, cultural understandings, experiences and meanings. (E.g. access to female GPs for Muslim

women).

5. The needs of vulnerable groups (travellers, refugees and asylum seekers) who are at a significant

geographic distance from available health services. Poor facilities in asylum reception centres. Poor

access to GPs and other mainstream services. Lack of information and understanding of services.

Poor access to transport. Travellers highlighted that their poor mental health status is closely

connected to low socioeconomic status, poor accommodation, low literacy skills, discrimination,

exclusion and marginalisation. Refugees and asylum seekers also reported that their poor mental

health status were particular to issues concerning the length of processing cases, (which can take

up to six years), limited access to information about rights and entitlements, poor access to advice

and support about health issues, and a lack of culturally appropriate mental health services.

6. Participation of minority ethnic communities: Service users are not regularly consulted about the

services they receive.

pg. 11

Priorities established by the NIHS Ireland

1. Information, language and communications. Improve access to information and cultural mediation;

provide professional interpretation and translation service and provision of training for community

interpreters

2. Service delivery and access to services. Provide services on the basis of equality of access in all areas of

service provision; provide better systems for inter-sectoral work and the coordination of services; and

develop a population health approach that links to the social determinants of health and links to health

inequalities

3. Changing the organisation. Ensure that the organisation reflects the diversity of Irish society; ensure

commitment in the leadership of the organisation to inter-culturalism and equality; enhance learning and

development of staff; and improve data collection.

4. Working in partnership with ethnic minority communities. Support and resource for minority ethnic

community groups in their work in tackling inequalities in health in local communities and in

representing the diversity of minority ethnic interests; ongoing participation and consultation with

minority ethnic communities in service developments and in the ongoing implementation of the Strategy.

(Pillinger, 2007)

The focus groups identified a range of barriers however these apply mostly in the primary health care area

like access to GP services and encompasses very little in relation to mental health services. It is however

noteworthy that some consultants did communicate that they felt as though they were being treated

“differently because of their skin colour”, or that they perceived second-class treatment by primary care

providers by virtue of holding a medical card. Regarding barriers and other service issues in mental health

care services, the majority of consultants emphasised the need to formulate culturally competent mental

health services, which take into consideration the religious/ belief of the patients. These concerns were

particularly expressed by users of direct provision reception centres, the Hatch Hall Reception Centre in

Dublin and Mosney Accommodation Centre in County Meath focus groups collectively reported that,

“having no possibility of work and a lack of constructive occupation, residents felt their mental health was

adversely affected. Where there was an in-house psychology service available within direct provision, these

were held to be working sufficiently well. However, this service was not available on site everywhere.” The

NIHS admittedly highlighted mental health in direct provision centres as a primary priority, however the

recommendations provided on the report in relation to direct provision and psychological care service

quality briefly states: “There should be a psycho-social approach to addressing the mental health needs of

people in the asylum process and the need for fast-tracking family reunification”, gender specific issues

have also been highlighted particularly in relation to FGM (female genital mutilation) and other gender

specific traumas in relation to vulnerable groups. Little is known about the development and efficiency of

these recommendations and if, indeed, they have been materialised and monitored. (HSE, 2008)

In an assessment in 2005 by CAIRDE research team, it was brought to light that 38% of the participants

stated that stress, anxiety or depression were the main reasons they were dissatisfied with their overall

health. These results emphasize the need for the development of a mental health care forum engaging

wider ethnic minority communities on a national level to explore further the barriers and pathways of

specific to the access to mental health services among immigrant minority ethnic groups in a new report

named, Mental Health Initiative 2014. The report will be concluded in late 2014. (CAIRDE, 2014)

pg. 12

An international example Changing Directions, Changing Lives is the first mental health strategy for Canada developed in 2012 as a

response to a report called ‘ Out of the shadows’ which the received the input of thousands of people

suffering from mental health issues across the country. Its purpose is to help improve mental health needs

and well-being for all people living in Canada and to create a mental health system that can accommodate

for the diversity of its population. In relation to vulnerable groups, the Canadian mental health strategy

seems to apply a preventative approach by improving the social antecedents of poor mental health status

affecting ethnic minorities.

Priorities established by Changing Directions, Changing Lives Canada

1. Make improving mental health a goal while working to enhance overall living conditions and

health outcomes.

2. Improve mental health services and supports by and for immigrants, refugees, ethno-cultural and

racialized groups.

3. Tackle the pressing mental health challenges in northern and remote communities. Strengthen the

response to the mental health needs of minority official language communities (Francophone and

Anglophone).

4. Address the specific mental health needs related to gender and sexual orientation.

Ireland still falls short of well establish inter/multicultural mental health online resource platform and

detailed and practical multicultural mental health policy framework. Ireland’s sole intercultural health

resource (CAIRDE) continues to fail to introduce informative resources for minorities and practitioners on

pathways of access and deliverance of quality multicultural mental health services, twelve years since its

establishment in 2002 the organisation initiated a project which seeks to increase participation of ethnic

minorities in mental health, including mental health services; community based mental health promotion

and mental health policy. The Canadian equivalent to CAIRDE is called the Multicultural Mental Health

Resource Centre (MMHRC) which seeks to improve the quality and accessibility of mental health services

for people of and ethnic backgrounds, including migrant workers, refugees, and members of established

ethnocultural communities e.g. Irish travellers, unlike CAIRDE the Canadian resource centre does dot

only focus on providing information for ethnic minorities on health services but for practitioners. The

NIHS first priority is to improve”… access to information and cultural mediation; provide professional

interpretation and translation services and provision of training for community interpreters.” However it is

noteworthy that on the CAIRDE website on 6xi languages are provided, none of which cater for the vast

majority of the Irish ethnic population (African [7.5%] and Asian[12%]) e.g. Lingala for Republic of

Congo immigrants and Hindi for Indians, whilst the MMHRC caters for 26 languagesxii, clearly diversity

within ethnic communities continue to be under recognised in Ireland. The following table is a compilation

of the services available for mental health professionals & multicultural service users looking for

information on mental health services:

Services Canada (MMCHR) Interpreters Resource provides links to lists of organizations and agencies which provide

access to interpreters and culture mediators, organized by province. http://www.multiculturalmentalhealth.ca/services/find-an-interpreter/

pg. 13

Local Ethnic Community Organizations

Provides list of community organizations for refugees, immigrants, and members of ethnolinguistic groups organised by province. http://www.multiculturalmentalhealth.ca/services/local-community-organizations/

National Health Organisations

Provides list of national/ multicultural organizations for refugees, immigrants, and members of ethnolinguistic groups. http://www.multiculturalmentalhealth.ca/services/national-level-organizations/

Ethnocultural Mental Health Practitioners

Provide a list of psychotherapy practitioners who serve specific ethnocultural communities by the languages they work with. Organised by province (5). http://www.multiculturalmentalhealth.ca/services/practitioners/

Cultural Consultation Service

Provides info of institutions which provide comprehensive assessment and evaluation of patients from diverse cultural backgrounds, including immigrants, refugees and members of ethnocultural communities. http://www.multiculturalmentalhealth.ca/services/consultation/

Patient Information

Provides patient information by age, by language (26) and by topic (e.g. depression). http://www.multiculturalmentalhealth.ca/clinical-tools/mental-health-information/

Clinical/ Expert Information

Provides list of Multilingual & Multicultural Screening Scales for both adults and Children. The Website also provides tool-kits to increase cultural competence. Provides guidelines for providing mental health care sensitive to the special needs of some specific populations:

1. Children and Youth 2. Seniors 3. Immigrants and Refugees 4. Workplace 5. Torture

Also provides health professionals with a list of resources with guidelines for working with Interpreters & Culture Mediators. http://www.multiculturalmentalhealth.ca/clinical-tools/assessment/ http://www.multiculturalmentalhealth.ca/clinical-tools/cultural-formulation/ http://www.multiculturalmentalhealth.ca/clinical-tools/guidelines/ http://www.multiculturalmentalhealth.ca/clinical-tools/working-with-interpreters/

Policy Provides material useful to policy makers and administrator involved in health care systems and services design, implementation and quality assurance e.g.:

1. Canadian Policy 2. International Policy 3. Methodologies

Policy related to specific topics:

1. Cultural diversity 2. Human rights 3. Immigration policy 4. Interpreters and culture brokers 5. Mental health promotion 6. Refugee policy 7. Stigma and discrimination.

http://www.multiculturalmentalhealth.ca/policy/

pg. 14

Training Provides links to Cultural Competence Training Materials and Programs for mental health professionals. Also provides a list of online self-assessment tool kits, video lectures and podcasts to help health care providers and other staff in assessing their overall cultural competence, identifying the weaknesses, and directing further professional growth. http://www.multiculturalmentalhealth.ca/training/cultural-competence/ http://www.multiculturalmentalhealth.ca/training/cultural-psychiatry/ http://www.multiculturalmentalhealth.ca/training/self-assessment/ http://www.multiculturalmentalhealth.ca/training/mmhrc-videos/

BLOG Linked to a blog which provides live updates on topics, debates, training etc. related to multicultural metal health care for practitioners and service users in English, French, Arabic, Chinese, and Farsi. http://www.multiculturalmentalhealth.ca/blog/

CONCLUSION Research on discrimination and health is in its infancy, however, the available evidence thus far suggests

that perceiving discrimination may affect health, through psychological and physiological stress responses

and other health related behaviours and coping strategies (avoidant or active). Not only has it been

established that 1. Perceived discrimination has a directly and indirectly pathway which has the potential

to affect an individual’s health, but also 2. That socioeconomic disadvantage, perceived and experienced

institutional discrimination in the shape of barriers of access to health services among ethnic minorities

and failure to acknowledge their specific cultural and health needs is also contributing to a continuous

disparity between the health status of ethnic minority groups and the majority group. Inevitable the

argument has taken a critical tone in the discussion of Irish multicultural health service care practices and

policy, particularly by bringing to light its short comings in the field of mental health. The paper has also

highlighted the vulnerable position of vulnerable groups (refugees, asylum seekers, Traveller group and the

Roma community) in access to appropriate mental health services. In addition the author sought to bring

to light the paramount relevance of the topic at this point in time, when perceived racism and racist

attitudes continue to rise in Ireland and when national economic difficulties will most likely lead to

continuous budget cuts for organisations working to develop on anti-discrimination policy.

“What is clear though is that discrimination may have serious consequences in terms of mental and

physical health, self-esteem and underperformance for the minority group, and the disadvantage

experienced by any one group may translate into intergenerational disadvantage. Measuring the extent of

discrimination, a key focus of this volume, is therefore an extremely valuable exercise.” (Laurence Bond,

2010)

pg. 15

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