The Essential Elements of Culturally Sensitive Psychiatric Services

242

THE ESSENTIAL ELEMENTS OF CULTURALLY

SENSITIVE PSYCHIATRIC SERVICES

KAMALDEEP BHUI, YVONNE CHRISTIE & DINESH BHUGRA

SUMMARY

The recent re-structuring of the British National Health Service (NHS) involving agreater emphasis on community treatment has not specifically taken account ofthe unequal access to mental health services experienced by black people. Thegreater use amongst black people of compulsory orders, police involvement andreliance on psychotropic medication, although well established, has not influ-

enced policy or led to a strategy to ensure that services appropriately meet theneeds of the culturally diverse population in this country. We present the literatureon service utilisation by black people and potential solutions in areaswith which black people are dissatisfied. The service structures, idoology andmechanisms presented form the foundations of good practice.

INTRODUCTION

Concern that ethnic minorities sutler disadvantage in gaining access lo psychiatricservices has produced tittle change in existing service structures (Littlewood ~ Lipsedge,1989; ~~~i~9 1982; Wilson, 1993). There is a considerable body of literature suggestingthat black people are over-represented amongst compulsory admissions to psychiatricfacilities and are more likely to be admitted with police involvement (Littlewood &

~,i~s~c~~~9 i~~~9 ~~~~~~~~ ~~ al. i994; Wilson, 1993). The differential use of treatmentsbetween different racial and cultural groups continues to be a grave concern ~~~~.~~~.91993; Femando, 1988). Black people are already a multiply disadvantaged group andinability to access existing services may be a factor for presentation in crisis (Bhui <?~ al.

i9~3jo Disadvantages in the recognition and treatment of mental illness amongst ethnicminorities continue to be identified 1988; Rack, 1982), yet there seems to belittle strategic long term planning to address these inequalities in health care at policy level.

Literature review

Throughout this paper the term ‘bi~~,i~9 be used to denote all racial and culturalgroups. This includes African or Caribbean, Chinese, Vietnamese, Indian, Pakistani andBangladeshi communities. The choice ofepidemiologically meaningful terms to describeblack people has received significant critical attention ~~~~°x~~~ ~ Phope,], .1.994.). Theauthors’ intention is not to regard all black peoples as a single ’undiSerentiated other’;health professionals should always take account of the diversity of cultures incorporatedunder the umbrella term. Although the term ’ethnicity&dquo; has largely replaced ’race’ as the

by guest on April 22, 2016isp.sagepub.comDownloaded from

http://isp.sagepub.com/

243

appropriate way to think of human difference, ethnic boundaries are not immutable andcan change according to historical political circumstances (Smaje, 1995). The purpose ofusing the term black is to increase clarity of thought about policy development rather thanadd to confusion about terms describing ethnicity (a social construction). The instabilityand lack of reliability of self denned or ascribed ethnicity (Leech, 1989; Smaje, 1995)further limits the validity of using ethnicity data in order to assist with the allocation ofresources and the planning of future services (Jarman, 1983, 1984; Hirsch, 1988).

P~c~M~’e services a~~~~c~~e~/e.’ <3~er<?~ rates ~,f c~~s~~°c~ea~?Operationally defined diagnoses of Schizophrenia have been reported to be moreprevalent amongst black people of African and Caribbean origin both in the UnitedStates and in the U.K. (Harrison, 1988, Littlewood & Lipsedge, 1988; ~’~rl~ et al. 1994).The data and the interpretation placed upon it has been criticised on methodologicalgrounds (Bhugra el a/. 1995; ~c~~r~~ie, 1995; ~e~°~a~d®9 1988 & 1995). This re-

appraisal is supported by data from the Epidemiological Catchment Area study in theU.S. where there was no reported difference in the prevalence rates of schizophrenia aftercorrection for age, sex, socio-economic status, and marital status (Adebimpe, 1994). Nodifference was reported between blacks and whites in the prevalence rates of anti-socialpersonality disorder, affective disorders, drug dependence and panic disorder. Racerelated differences were demonstrated for phobic disorders, generalised anxiety dis-orders and somatisation disorders which were more frequent in blacks; obsessive

compulsive disorders were under represented. However, British studies indicate thatbiack people are less likely to receive diagnoses off anxiety or depression in primary care(Gillam, 1989). This is paradoxical as causal factors in anxiety and depressive disordersare amongst the socio-cultural explanations put forward to account for higher rates ofschizophrenia amongst black people (Lloyd, 1993); consistent with this hypothesis arestudies indicating higher rates of anxiety and depressive disorders amongst blackprimary care attenders (~~ievg i 965). Burke (1984) suggests that non recognition byGPs is responsible and reported that GPs failed to make a diagnosis in up to 21.3% ofblack patients and up to 12.8% of white patients identified as ill by a screeninginstrument. tra some instances the excess prevalence of a specific disorder amongst aparticular racial, cultural and religious group can be related to their historical experienceof adversity. Thus Hinton ei t!/. (1993) demonstrated that i~.~®/a of Vietnamese andChinese refugees had one or more psychiatric disorders. Vietnamese had higher races ofpost traumatic stress disorders explained by their experiences of more traumatic eventsincluding separation from families. On the whole the findings remain controversial asany relationship is likely to be complex and not easily modelled. A relationship betweenrace, ethnicity and specific diagnosis is also demonstrated in American studies but thereappears to be no generalised pattern applicable across racial groups (Flaskcrud & Hu,i 99~).

MeM~/v ~~.s®rci~~°e~ q~~e~ and Block ~~®~~~Black people of African our Caribbean origin are over-represented within the Britishcriminal justice system as offenders and are under-represented as representatives ofvarious agencies of the Criminal Justice system (C.J.S.; NAPO, 1989; T~J~~~~, 1989,



244

1990 & 1992; Cope, 1992). The lack of Black representation within such agencies adds toBlack people’s perception that racism is a factor in the outcome of their cases (Reed,1994). Although studies confirm a higher rate of police referral to psychiatric hospitalsfor Black Caribbean patients (Rogers & Faulkner, 1987; Turner et al. 1992) this appearsto be a consistent finding amongst emergency admissions even where the police are notinvolved (Fahy, 1987). A smaller range of possible disposals from prison have beenreported for black remanded men in previous studies in examining court diversion(Hood, 1993; NACRO, 1989). Not surprisingly mentally ill black people are over-represented amongst remand prisoners transferred to hospitals from prison (Banerjeeet al. 1995). This is in accord with population surveys finding a higher rate of psychoticillness amongst black people whilst in prison and that those in special hospitals aredetained because of an identified psychotic illness (Maden, 1993). Furthermore, Taylor(1986) showed that of all her sample of life sentenced prisoners being supervised in thecommunity, 10% had a diagnosis of schizophrenia and of these 41 % were born in theWest Indies. Yet very few black people were admitted to Grendon (a prison specialisingin the rehabilitation of prisoners with personality disorders), again suggesting less healthcare service contact (Cope, 1992). In the U.K. Regional Secure Units (part of the NHS)also contain an excess of minorities (Jones & Berry, 1986). A similar picture emerges insthe USA where Black alcoholics are less often treated in hospital and more often end upin gaol compared to a white population (Pasamanick, 1963). Furthermore, althoughBlack, Hispanic and White offenders in the USA are equally affected by epilepsy or drugabuse it seems that white offenders have been in contact with psychiatric services moreoften (Novick et al. 1977).Two hypotheses are commonly cited to account for these findings (Maden, 1993). It is

suggested that mental illness is over-diagnosed amongst Black offenders (of African andCaribbean origin) explaining higher rates amongst forensic psychiatric populations.Secondly it is reported that mental illness goes unrecognised in most black offenderswhose behaviour is labelled as ’bad’; this would explain the higher contact with criminaljustice agencies. Black people being perceived as more threatening may account for somedegree of rnisdiagnosis (Bolton, 1984) but difficulties of conmunication and a failure ofinterventions/aftercare when illness is not recognised is also instrumental (Pasamanick,1963; Lewis et at. 1979; Dolan et at. 1991; Perera et al. 1991). However, reports of linksbetween ethnicity and crime do not always comprehensively contextualise the presenteddata and wider cultural influences on crime may be neglected (Maden, 1993). Furthermore,although there are errors in reporting and recording of official statistics pertaining to crime,culture, skin colour and mental disorders, rates of particular offences cannot be reduced toan index of criminality and then generalised to others of the same skin colour or culture(Maden, 1993). Offence specific rate comparisons are one solution but the ethnic origin of theoffender will affect reporting and recording (Stevens & Willis, 1979; Radlett & Pierce, 1985).

Francis (1994) with a title of ’No More E.~CM~~ draws to the attention of professionalsthe plight of Black patients in Great Britain emphasising that the Ritchie report, whichoutlines the case of Christopher Clunis is describing a common scenario of Blackexperience. Despite the persistent production of data on the subject little focused changehas been witnessed in the structure or procedures within existing services at a nationallevel. We draw on the literature on service use amongst Ethnic Minorities and propose a



245

range of mechanisms and service structures necessary in a culturally sensitive mentalhealth service (see Table).

The elements of a comprehensive culturally sensitive serviceThe principle of setting up services in the community has to be the equitable provision ofservices to all users (Bhugra, 1993), but as the patterns of accessing and using servicesamongst black people differ and as the range of component structures, interventions andpersonnel that sensitive services should include is likely to differ for cultural minorities,specific attention should be addressed to meeting the needs of black people. Thus nomeasures taken are likely to succeed if the structural components of a comprehensivemental health service are absent. Hence, all services should be local and accessible,

~~b~~Essential elements of psychiatric services for black people



246

comprehensive, -flexible, consumer orientated, should empower clients, should focus onstrengths, should be normalised and incorporate natural supports, should meet specialneeds, be accountable and be racially and culturally appropriate (Stratbdee & Thorni-

croft, 1994). The National Institute off Mental Health’s formulation of a model planinvolves needs led, components led and functional models of service development(NIIB1H, 1987). Initially the model most suited to black people involves a &dquo;bottom up’approach namely the needs model, but if ongoing consultation with local blackcommunities is established then the other models could also be deployed successfully.The setting of sector boundaries should be followed by an estimation of populationneeds as a whole and specifically identifying the local black communities to be targeted.This should be incorporated into the planning process with a mechanism to ensure it isrepeated at regular intervals. Thus information systems addressing the size of the localpopulations, local vulnerabilities, the known rates of disorder, and indices of deprivation(for example Jarman) are essential. The following are the elements which are oftenoverlooked and need special emphasis to ensure that the cultural sensitivity of develop-ing services is considered throughout the planning and implementation process and notas an afterthought whereby the provision of quality services for black people would becompleted later than all other stages.

COnIm1u¡nkation and lB!formatnon

7M~pr<?~~The range of language skills provided should renect that of the local population. Afactor often overlooked is that mental health. interpreters need special training as doprofessionals making use of them. Sharing a language is insumcicnt alone to capture acommunication of distress and is with pitfalls (Westermeyer, Black usershighlight their preference for the involvement of bilingual staff rather than interpreters(NHS Executive, 1994’. Potential breaches of confidentiality and the risk of one’scommunity becoming aware of one’ mental ilmcss may deter some people from seekingheip through an interpreter (or professional) who also belongs &dquo;to their community; theuse of advocates has been encouraged to overcome this problem (Rack, I. 982).

A ~MM/~-ag~C}’ ~:~~~s~~~~a~y~e~,~r~~~~rCommissioning conferences have been presented as ~3 creative mechanism for purchasersto consult with local residents, improve local services and maintain working relation-ships with providers eat ~~. 1994). Such a forum may be applied to purchasingservices for ethnic minorities and should actively involve the voluntary sector. This isessential for eliciting opinions from local users and communicating these ideas to healthand social care workers and ~~~~~~~~s. Such meetings should be held regularly andespecially at times of service re-structuring. Black people’s mistrust and suspiciontowards psychiatry needs to be addressed before any service can hope to succeed(Bhugra, 1993). A top down approach to service development is doomed to failure(Bhugra, 1993). Information should be regularly disseminated snd should, includeimmediate and future planned service developments. Local community groups andrepresentatives of social and religious bodies act as one route conveying information. -.



247

.~~~~~~~®~°~~~A greater awareness amongst health care professionals about culturally sensitive servicesalready in existence is necessary. Each locality should have a register or directory of allagencies and contact persons for all local organisations. Directories would also beinvaluable to patients and providers who wish to identify rapidly the most appropriateagencies to deliver specific interventions that would complement a comprehensiveculturally appropriate treatment plan.

public health education

Specific campaigns directed ~.~ Black people should be encouraged and should take theform of and 6s~~i~i,~~’ ~~~.~~~s (Winner 1989). The view that health educationneeds of black people diner and hence the techniques should also is not new (Bhopal,199 Each modality should be especially chosen in the context of targeted groups.Translated information should de-mysiify psychiatric disorders and their treatment andshould be easily available.

of he~îth C21¡re services

A :~c~c~‘e~~~,~a~~ to needThe range of services available should ~°~~~~$ the needs of the local population. Thedetailed age, sex, and cultural structure of the local black population needsto be established before planning. In inner city areas population demographics maychange rapidly and the range of services available may always lag behind demand. Amechanism to buy in appropriate services where none exist locally or where demand isinsufficient z~~~~~;i~~r long term ~i~~~3~i~~ investment is only one solution. Black voluntaryorganisations may be the important providers of such services in the future. Validmeasures of loca! population or individual based needs assessment are required. Theseshould be simple and quick to apply. The care programme approach includes amechanism yet the outcome amongst black people needs evaluation. The developmentof culturally sensitive needs assessments presents a challenge to providers; involvementof users and their families in this process at an individual level is essential.

Yet, the ideological exercise of developing a multicultural needs assessment may befailed by 11) a lack of effective interventions (e.g. for treatment resistant

psychosis), ii) the unavailability of interventions which Black people wish to use (e.g.psychological, talking ~i~~r~~~~.~s3, iii~ the absence of services locally to deliver thoseinterventions taking account of cultural differences including language (e.g. family7vorEi), iv) the jack of scientific data to promote a potential treatment desired by thepatient to the level off an effective intervention (e.g. reflexology, ~~’~~~~’~~~~~~~1~ herbalremedies). The types of service ethnic minorities ask for may not be available locally,may be regarded as being of suspect cnicacy or indeed just not medically indicated. Eachspecinc cultural group may place unique demands on service provider units, stretchingtheir established and largely evidence based range of interventions. Local assessments ofpopulation need, the receptivity of purchasers to the black community’s views, purcha-ser contracting and ~6~° course locally available resources will be influential on howprovider units respond.



248

One approach adopted in the United States is to use generic services and set up withinthem ’focus teams’; each team addressing the needs of specific communities who have asignificant profile locally (Dillard et al. 1992). Each team is charged with a task tofamiliarise themselves with the community and allow the community to access theirknowledge and skills. This approach, linking ethnographic information to facilitate thestrategic evolution of the service, avoids fragmentation of services and ensures thatcultural knowledge is developed and retained within the team despite staff turnover.Such an approach, although not standardised for all groups, encompasses the flexibilityof approach necessary for a culturally sensitive assessment of need (De Mars, 1992)without the expectation that patients should have to adapt to existing services and theirprocedures.Admission procedures and the ward environment should be designed taking account

of the cultural diversity of Black people. Units should ensure that religious and culturalpractices are supported. This includes the involvement of religious leaders, whosesupport and care of individuals extends to their spiritual and social needs, as well asattendance at a place of worship. Each agency (acute ward, rehabilitation ward, dayhospital, general practice etc.) should indicate which features of their service are

designed to meet the needs of black people (e.g. choices of food in hospitals, women .only services, day centres and where meals on wheels services are accessible).

A range of locally available and flexible treatment packagesThe development of local, more appropriate packages of care should be encouraged.Users must have a channel to influence such developments in the context of otheradvances identifying effective interventions related to new medications and innovativepsychological strategies. For example instead of being admitted to an inpatient ward,linguistically and culturally isolated women may be better cared for in their familiarhome environment with either the help of their family, or support from a 24 hour crisisservice. This avoids an enforced admission onto an acutely disturbed, mixed sex andculturally unfamiliar environments. Treatment preferences of black people should begiven consideration (however unfamiliar to the professional) with an explicit documen-ted assessment of decision-risk informing the eventual outcome (Carson, 1994; Hatcher,1995). This is especially important where decisions about detention and compulsorymedication are considered as it is in these areas that many black people feel especiallyaggrieved and unheard (Wilson, 1993; NHS Executive, 1994).

MedicationBlack users have voiced their dissatisfaction with excessive use of medication, theadverse effects of which are often more intolerable than some of the original targetedsymptoms (Wilson, 1993). Differences in sensitivity to alcohol, response to anti-

depressant medication, response to neuroleptic medication and other psychotropicshave been demonstrated between cultures and races (Lin et al. 1989; Takahashi et al.1975; Raskin et al. 1975; Glazer et al. 1994; Yamashita, 1992). The recent changes inpractice regarding the prescription of high doses of neuroleptics are to be welcomed(Sims, 1994). Perhaps it is similarly time to challenge views about medication amongstBlack people who are known in Britain to receive major tranquillizers and anti-



249

depressants more frequently than White patients, more often as a depot, at higher doses,and less often psychotherapy or counselling (Littlewood & Lipsedge, 1989; Moodley &Perkins, 1991; Lloyd & Moodley, 1992). Black users’ complaints about medication maybe a result of excessive medication in the face of poorer communicative relationshipslending themselves to pursue a biological approach. This situation may also rehect alower threshold amongst Black people to developing adverse effects. Glazer et al. (1992)support this view with the findings that non-whites were 1.83 times more likely todevelop tardive dyskmesia (TD) than the white population, yet Chiu eat c~~. (1992) in theirstudy of a Chinese population demonstrate a lower prevalence of TD (9.3%) thanformerly reported amongst western patients. This suggests that each racial group mayhave unique pharmacodynamic and pharmacokinetic response. This statement shouldbe received with caution, as emphasising racial difference historically has led to

disadvantage amongst ethnic minorities (Fernando, 1988); yet the denial and lack ofexploration of genuine pharmacological differences perpetuates the notion that Blackpatients, complaints about medication are unwarranted.

Lin et al. (1989) demonstrate this variation in required dose in the treatment of Asianand Caucasian patients with schizophrenia. During the fixed dose stage of this study,Asians always had higher serum levels of haloperidol and more extrapyramidalsymptoms. During the variable dose stage Asians required lower doses for similardegrees of symptomatic control. Japanese patients also respond to lower serum levels ofLithium and dosages of chlorpromazine during the treatment of manic episodes than doWestern patients (Takahashi et al. 1975). Black patients have been reported to have ahigher placebo response (Goldberg et al. 1966) and a better short term response toanxiolytic and sedative drugs (Takahashi et c~l. 1975). Raskin (1975) also differentiatesbetween the effectiveness of imipramine and chlorpromazine in Black men and women,suggesting that Black women’s ratings on anxiety, tension and sleep disturbance wereespecially improved at three weeks whereas Black mean improved more on depressionand social participation. White men and women did not differ. The possibility of racialand gender interactions to produce race/sex specific pharmacokinetic and pharmaco-dynamic profiles warrants further study. Cultural attitudes and medication as a symbolof social control and loss of autonomy are likely to further add to the complexity ofpatient-medication interactions rendering simple reductionist descriptions for specificethnic groups as flawed. A closer working relationship with pharmacists, systematic drugreviews, and a national standard of care is essential.

Psychotherapy servicesWilson (1994) states that Black people prefer psychotherapy and other complementarytreatments as an alternative to medication. Frank (1973) has asserted that the quality ofthe therapeutic relationship is more important than the theoretical perspective of thepsychotherapeutic model applied but also that patients obviously have to have faith inthe approach if it is to succeed. Perhaps it is at the ’quality of relationship’ and ’faithin method of healing’ chosen that Black people are becoming dissatisfied and hence notpursuing or not being referred for existing psychotherapies. ’Whilst exact figures on thenumbers of black people offered formal psychotherapy have never been published by theTavistock or the Institute of Psychoanalysis the impression has been that the numbers s



250

are very small’ (Littlewood, 1998). ’A common statement perhaps muted recently, hasbeen Lhat psychotherapy is essentially culture bound to the western middle class milieu inwhich it was practised by this class for themselves and that it is not appropriate for thenon=European patients who are themselves less verbally sophisticated, less psycholc-gized, preferring to express their distress through a different idiom-somatic, religious orwhatever’ (Littlewood & Lipsedge, 1989). ’All societies make distinctions betweendesired and undesired states of being, and have standardised forms of reconstructingexperience, through the response of other people to return the individual to a statedesired by the individual and community alike. At such a level of abstraction therapy isuniversal’ ~~itti~~~r®®d, 1993). Thus western models of psychotherapy may be unfamiliarto minority groups; this is not the same as a common inference that minority groupsbecause of their lack of historical experience with western psychotherapy lack the abilityto use such services.

A~T~, an intercultural psychotherapy centre provides further evidence of this.Therapists at this centre have practised intercultural therapy for many years withsuccess. The centre deiiberately set itself against ethnic matching except where issuesof language made it impossible (Karceiii ’l L--Ittiewood, 1992); patients are allowed tochoose their therapist and attend sessions with an advocate. The gender and racial .

politics of such matching have been given considerable attention (Littlewood -8i

~,i~s~d~~5 1989; ~~~~~~~~a & Littlewood, 1993; Fernando, I- 9’08). Flaskerud and Lin(1990) examined 1746 Asian client contact episodes; where urban client and therapistshared the same language there were more attended sessions but no cumulative benehcialeffects. Yet many black organisations stil’~ suspect and voice that black experience cannot be understood unless the therapist has first hand experience of being black. Shouldthe client’s own preference be taken account of ~ Certainly there exist cases whereby aperson asks for therapy to be conducted in the English language despite at being a secondlanguage; similarly a refusal to see a therapist from the same ethnic group and culturehas often been cited by patients who wish to disclose and discuss acts or events which aretaboo within their own culture. Therapists trained in therapy techniques areessential to any service attempting to meet the needs of black people. Adaptations toexisting ~~°~~t~~~~t methods to suit black people should be explored. If a client rcquesf.5 ablack therapist, do services have the ncxibility of work practice and financial arrange-ments to accommodate such i7equests? Linguistic difficulties or cultural ofservices may be the explanation offered for lower psychotherapy referral rates amongstback people, yet black people can benefit from a range ofpsychotherapeutic models andindeed often prefer it to medical approaches ~~~~.~~~~ ~ ~itti~~~~~_~ i9~~~. Certainly theapplication of any model must be preceded by a shared understanding of the process ofpsychotherapy and inevitably this would require more sessional time. Perhaps in accordwith Black users, views ’buying in’ culturally appropriate therapists familiar with theculture and language makes more clinical and financial sense than undertaking a greaternumber of treatment sessions with the use of an interpreter (NHS Executive, 1994).

F~m7}’ iaeefings throvgliotit i~ci~~a~r~a~~ ~c~~i~,~~i~a~ and ~~e~~~i~~ct ~o~a~~~~ lFamily therapies are of value in the management off schizophrenia and can effectively beused by ethnic minorities. In cultures where an individual’s identity and sense cf self and



251

persormood are linked to that of the family, distress is likely to be manifest in

interpersonal terms as social dilemmas or family distress ~~~lii~~~.9 1991; Marsella &White, 1982). Treating the individual as if he/she were entirely autonomous, a positiveattribute of individual personality in the west but not so in many other cultures (Marsella& White, 1982), may be ineffective but also neglects and denies a self defined role offamilies in many non-western cultures in providing care for ill relatives ~~~z~f‘c~rd91994). Families should be involved in regular meetings to discuss treatment options evenif formal therapy sessions are not indicated, and such involvement has been demon-strated to be especially important for the families of Black mentally ill people (Lm et ol.1991)~ The reluctance of statutory sectors to acknowledge the importance of the familyand to develop services to support the dependants in Black families often leaves Biackparents unsettled and suspicious of the long term intentions of social and health careservice structures.

~~~a~~i~~t~ta~~~Rehabilitation agencies should positively value and encourage identification with thepatients own cultural or religious group. Much of the distress faced by minorities(Fernando, 1 9sg j Wilson, 1993) is not acknowledged and existing services largely neglectposidve inclusion of cultural and religious activity as part of a care plan and thus fail tonurture Black people’s cultural identity. Appropriate local voluntary group contact andleisure activities should pro-actively be encouraged and may have to be especiallyarranged (Mumfbrd, 1994).

Black ~~t~~~d~~~e~~9s needs m relation to hospital facilities and care at home differ sufficiently for aseparate consideration. There are different degrees and types of religious participation aswell as acceptable degrees of privacy. The social signincance of mental illness also differsfor women and one cannot assume that male centred services are sumcient. ?’omen°straditional role in some cultures as the primary carer of children has a signincantinfluence on the manner in which distress is manifest and must therefore be takenaccount of in any treatment package offered. Popular methods of child care and~~~g~~~;~~9s perceived roles in the U.Li. cannot readily be assigned to Black women. Theimpact of strcssors and the experience of adversity, for example separations, cannot bereadily understood and hence attributed across cultures (~~c~~rth~ ~ Craissati, 1989).Black ~~.~rr~~~’s roles are likely to place unique expectations and demandthe fuinlment of specific obligations. The impact on Black women of the interaction ofthese roles with existing health services needs more exploration. Black ~®~~~9s

involvement should be encouraged in developing appropriate levels and models off care.

Mew ~~~~i~~~ sedbi care poiicyi evaluzltion amongst black peopleHealth Service re-structuring should routinely evaluate the impact of new models ofservice delivery (and the accompanying service structures) amongst black people and notperpetuate the imbalance of health care by relying on pilot schemes which do notspecincally involve black professionals and patients. For example, we do not know howesective court diversion, prison diversion and care management are for black groups.



252

Already alienated to existing services, the wave of new developments in services notevaluated can only result in further disadvantage. Access to social care may also beprohibitively complex if language and customs inhibit the successful completion offorms and other criteria required by social service offices. Each organisation warrants anevaluation of the progress black people make in negotiating institutionalised barriers.

Black organisationsBlack mental health teams should be available in each locality not to deal with all blackpeople with mental health problems but to: a) raise the profile of the needs of local blackpeople, b) act as a resource for other agencies and c) to contribute to the training ofhealth care workers. As such close links between local black organisations and healthcare agencies is essential this should be manifest as routine consultation and attendanceat meetings of clinical and educational value. Black led organisations, as an informedvoice for black opinion, are essential to the development of culturally sensitive mentalhealth services and should be seen as an integral part of community mental healthservices. Such organisations are often under funded and not infrequently, although illequipped in terms of training to do so, seek funds in order to maintain existing levels ofcrisis work (Wilson, 1994). -

Staff and institutions’Racial discrimination was a strong factor in the treatment of Christopher Clunis. Acommon pattern emerges in the way in which Clunis was treated’ (Francis, 1994). Thismay be how black people are treated and experience their treatment within the existingsystem of healthcare. Racism is often institutionalised and hence may become part of thecommissioning process. Black people may be stigmatised by their own communities orindeed their own communities may not recognise them to be ill. This can further add toisolation or the instigation unsuccessfully of other coping strategies. All employees andusers should know which senior official to contact in the event they experiencedisadvantage based on their colour or culture; such disadvantage has been demonstratedduring the rccruitment of medical students (McKeigue et al. 1990; Bhopal, 1991b) buthas not prevented black people from being well represented in psychiatry (Littlewood &Lipsedge, 1989). Each organisation’s policy on racial harassment should be explicit.Health care workers including psychiatrists, regardless of their own cultural back-ground, should be involved in some sessional time devoted to black organisations;perhaps cross-cultural psychiatry training attachments will be encouraged so that allprofessionals regardless of their eventual career intentions have some experience in thisarea. The presence or absence of such posts could serve as one measure of culturalsensitivity of services. Other measures may include targets for employment of bilingualstaff, a clear strategy to involve Black advocates and targets for specified service

improvements which are annually reviewed.

Key Points- Black people suffer multiple disadvantages in gaining access to psychiatric services- Despite the extensive re-structuring of health services little attention has been directed

to specific evaluations amongst black people



253

- The development of more flexible care packages requires a partnership betweenprovider units and black patients and professionals

- Training in cross-cultural psychiatry is essential for all mental health professionals- Black voluntary organisations have a significant role to play in the development and

provision of culturally appropriate services as well as in the training of mental healthprofessionals

REFERENCES

ADEBIMPE, V. (1994) Race, Racism and Epidemiological Surveys. Hospital & Community Psychiatry, 45, 27-31.BANERJEE, S., O’NEILL-BYRNE, K., EXWORTHY, T. & PARROTT, J. (1995) The Belmarsh Scheme. A

prospective study of the transfer of mentally disordered remand prisoners from prisons to psychiatricUnits. British Journal of Psychiatry, 166, 802-805.

BELLIAPA, J. (1991) ’Illness or Distress?’ Alternative Models of Mental Health. Confederation of Indian Organisations.

BHUGRA, D. (1993) Setting up services for ethnic minorities. In: Dimensions of Community Mental HealthCare (Eds. M. Weller & M. Muijen). London: Saunders.

BHUGRA, D., LEFF, J. & MALLETT, R. (1995) Psychotic illness in ethnic groups. British Medical Journal,310, 331.

BHUI, K., SUFRAZ, R. & STRATHDEE, G. (1993) Asian inpatients in a District Psychiatric Unit.International Journal of Social Psychiatry, 39, 208-220.

BHOPAL, R. (1991a) Health education and ethnic minorities. British Medical Journal, 302, 1336.BHOPAL, R. (1991b) Effects of discrimination on careers of British medical graduates. British Medical

Journal, 302, 235.BOLTON, P. (1984) Management of compulsorily admitted patients to a high security unit. International

Journal of Social Psychiatry, 30, 77-84.BURKE, A. (1984) Racism and psychiatric disturbance amongst West Indians in Britain. International Journal

of Social Psychiatry, 30, 50-68.CARSON, D. (1984) Risk Taking With Mentally Disordered Offenders. Southampton: SLE Publications.CHIU, H., SHUM, P., LAU, J. et al. (1992) The prevalence of tardive dyskinesia, tardive dystonia and

respiratory dyskinesia among Chinese psychiatric patients. American Journal of Psychiatry, 149, 1081-5.COPE, R. (1992) Psychiatry, ethnicity and crime. In: Forensic Psychiatry (Eds: R. Bluglass & P. Bowden)

London: Churchill Livingstone.DE MARS, P. (1992) The Occupational Therapy Life Skills Curriculum Model for a Native American Tribe: a

health promotion programme based on ethnographic field research. American Journal of OccupationalTherapy, 46, 727-735.

DILLARD, M., ANDONDIAN, L., FLORES, O. et al. (1992) Culturally competent occupational therapy in adiversely populated mental health setting. American Journal of Occupational Therapy, 46, 721-725.

DOLAN, B., POLLEY, K., ALLEN, R. & NORTON, K. (1991) Addressing racism in psychiatry: Is thetherapeutic community model applicable. International Journal of Social Psychiatry, 37, 71-9.

FAHY, T. (1987) Police admission to psychiatric hospitals: A challenge to community psychiatry? Medicine,Science and the Law, 27, 263-268.

FERNANDO, S. (1988) Race & Culture in Psychiatry. London: Tavistock/Routledge.FERNANDO, S. (1995) Study did not deal with category fallacy. British Medical Journal, 310, 331-332.FLASKERUD, J. & HU, L. (1992) Relationship of ethnicity to psychiatric diagnosis. Journal of Nervous and

Mental Disease, 180, 296-303.FLASKERUD, J. & LIU, P. (1990) Influence of therapist ethnicity and language on therapy outcomes of

South East Asian clients. International Journal of Social Psychiatry, 36, 18-29.FRANCIS, J. (1994) No More Excuses. Community Care, 16-22 June: 21-23.FRANK, J. (1973) Persuasian and Healing. Baltimore: Baltimore Press.GILLAM, S., JARMAN, B., WHITE, P. & LAW, R. (1989) Ethnic differences in consultation rates in urban

general practice. British Medical Journal, 289, 953-957.GLAZER, W., MORGENSTERN, H. & DOUCETTE, J. (1993) Race and tardive dyskinesia among

outpatients at a CMHC. Hospital & Community Psychiatry, 45, 38-42.



254

GOLDBERG, S., SCHOOLER, N. & DAVIDSON, E. (1966) Sex and race differences in response to drugtreatments among schizophrenics. Psychopharmacologica, 9, 31-47.

HARRISON, G., OWENS, D., HOLTON, A. et al. (1988) A prospective study of severe mental disorder inAfro-Caribbeans. Psychological Medicine, 18, 643-57.

HATCHER, S. (1994) Decision analysis in psychiatry. British Journal of Psychiatry, 166, 184-190.HINTON, W., CHEN, Y., DU, N. et al. (1993) DSM III-R disorders in Vietnamese refugees. Prevalence and

correlates. Journal of Nervous and Mental Disease, 181, 113-22.HIRSCH, S. (1988) Psychiatric Beds and Resources: Factors Influencing Bed Use and Service Planning. Report

of a working party of the section for social and community psychiatry of the Royal College ofPsychiatrists. London: Gaskell.

HOOD, R. (1992) Race & Sentencing, Oxford: Clarendon Press.JARMAN, B. (1983) Identification of underprivileged areas. British Medical Journal, 286, 1705-1709.JARMAN, B. (1984) Validation and distribution of scores. British Medical Journal, 289, 1587-1592.JONES, G. & BERRY, M. (1986) Regional secure units, the emerging picture. In Current Issues in Clinical

Psychology IV (Ed. G. Edwards) London: Plenum Press.KAREEM, J. & LITTLEWOOD, R. (1992) Intercultural Therapy. Themes, Interpretations and Practice.

Oxford: Blackwell Scientific Publications.

KIEV, A. (1965) Psychiatric morbidity of West Indians in an urban group practice. British Journal ofPsychiatry, 111, 51-56.

KING, M., COKER, E., LEAVY, G. et al. (1994) Incidence of Psychotic illness in London: comparison ofethnic groups. British Medical Journal, 309, 1115-9.

KRAUSE, I. (1989) Sinking Heart: A Punjabi Communication of Distress. Social Science and Medecine, 29, 563-575.LEECH, K. (1989) A Question in Dispute: The Debate about an ’Ethnic’ Question in the Census. London:

Runnymede Trust.LEWIS, D., BALLA, D. & SHANOK, S. (1979) Some evidence of race bias in the diagnosis and treatment of

the juvenile offender. American Journal of Orthopsychiatry, 49, 53-61.

LIN, K., MILLER, M., POLLAND, R. et al. (1991) Ethnicity and family involvement in the treatment ofschizophrenic patients. Journal of Nervous and Mental Disease, 179, 631-3.

LIN, K., POLAND, R., NUCCIO, I. et al. (1989) A longitudinal assessment of haloperidol doses and serumconcentrations in Asian and Caucasian schizophrenic patients. American Journal of Psychiatry, 146, 1307-1311.

LITTLEWOOD, R. (1988) Towards an Intercultural Therapy. Journal of Social Work Practice, 3, 8-19.LITTLEWOOD, R. & LIPSEDGE, M. (1989) Aliens & Alienists. Ethnic Minorities and Psychiatry. London:

Unwin Hyman.LITTLEWOOD, R. (1993) How universal is psychotherapy? In: Intercultural Therapy. Themes, Interpretations

and Practice (Eds: J. Kareem & R. Littlewood). Oxford: Blackwell Scientific Publications.LLOYD, K. (1993) Depression and anxiety amongst Afro-caribbean general practice attenders in Britain.

International Journal of Social Psychiatry, 39, 1-9. LLOYD, K. & MOODLEY, P. (1992) Psychotropic medication and ethnicity: an inpatient survey. Social

Psychiatry. & Psychiatric Epidemiology, 27(2): 95-101.MACCARTHY, B. & CRAISSATI, J. (1989) Ethnic differences in response to adversity. Social Psychiatry &

Psychiatric Epidemiology, 24, 196-201MADEN, T. (1993) Crime, culture and ethnicity. International Review of Psychiatry, 5, 281-289.MARSELLA, A. & WHITE, G. (Eds.) (1982) Cultural Conceptions of Mental Health and Therapy. Dordrecht:

Reidel.

MCGOVERN, D., HEMMINGS. P., COPE. R. & LOWERSON, A. (1994) Long term follow up of youngAfro-Caribbean Britons and white Britons with first admission diagnoses of schizophrenia. Social

Psychiatry and Psychiatric Epidemiology. 29, 8-19.MCKEIGUE, P., RICHARDS, J. & RECHARDS, P. (1990) Effects of discrimination by sex and race on the

early careers of British medical graduates during 1981-7. British Medical Journal, 381, 961-4.MCKENZIE, K. (1995) Accuracy of variables in describing ethnic minority groups is important. British

Medical Journal, 310, 333.MOODLEY, P. & PERKINS, R. (1991) Routes to psychiatric inpatient care in an Inner London Borough.

Social Psychiatry and Psychiatric Epidemiology, 26, 47-51.MOORHOUSE, S. (1993) Quantitativs research in intercultural therapy: some methodological considerations.

In: International Therapy, Themes, Interpretations and Practice (Eds: J. Kareem & R. Littlewood). London:Blackwell Scientific Publications.



255

MUMFORD, D. (1994) Transcultural aspects of rehabilitation. In: Rehabilitation for Mental Health Problems,(Eds. C. Hume & I. Pullen) London: Churchill Livingstone.

NAPO (1989) Black people and remands into custodv. Brief from the Criminal Justice Committee, NationalAssociation of Probation Officers. London.

NACRO (1989) Race and Criminal Justice. A Way Forward. National Association for the Care andResettlement of Offenders. London.

NACRO (1990) Black people, mental health and the courts. An exploratory study into the psychiatric remandprocess as it affects black defendants at magistrates’ court. National Association for the Care andResettlement of Offenders. London.

NACRO (1992) Black people working in the criminal justice system. National Association for the Care andResettlement of Offenders. London.

NATIONAL INSTITUTE OF MENTAL HEALTH (1987) Towards a Model Plan for a ComprehensiveCommunity Based Mental Health System. Washington D.C. NIMH.

NHS EXECUTIVE (1994) Black Mental Health: A dialogue for change. NHS Management Executive: MentalHealth Task Force.

NOVICK, L., PENNA, R., SCHWARTZ, M. et al. (1977) Health status of the New York city prisonpopulation, Medical Care, 15, 205-216.

PASAMANICK, B. (1963) Some misconceptions concerning differences in racial prevalence of mental disease.American Journal of Orthopsychiatry, 33, 72-86.

PERERA, D., OWENS, G. & JOHNSTON, E. (1991) Disabilities and circumstances of schizophrenic patients- a follow up study. Ethnic aspects: three matched groups. British Journal of Psychiatry, 159, Suppl 13,40-42.

RACK, P, (1982) Race, Culture and Mental Disorder. London: Tavistock Publications.

RASKIN, A., THOMAS, H. & CROOK, M. (1975) Anti-depressants in black and white inpatients.Differential treatment to controlled treatment with Chlorpromazine and Imipramine. Archives of General Psychiatry, 32, 643-649.

RADLETT, M. & PIERCE, G. (1985) Race and prosecutorial discretion in homicide cases. Law & SocietyReview, 19, 587-621.

REED, J. (1994) Review of Health and Social Services for Mentally Disordered Offenders and others requiringsimilar services. Volume 6: Race, Gender and equal opportunities. London: HMSC.

ROGERS, A. & FAULKNER, A. (1987) A Place of Safety. London: MIND. SENIOR. P. & BHOPAL. R. (1994) Ethnicity as a variable in epidemiological research. British Medical

Journal, 309, 327-330.SIMS, A. (1994) High dose anti-psychotic treatment. Advances in Psychiatric Treatment, Issue I, 1, 16.SMAJE, C. (1995) Health, Race and Ethnicity. Making Sense of the Evidence. London: King’s Fund Institute.STEVENS, P. & WILLIS, C. (1979) Race, Crime & Arrests. Home Office Research Study no 58. London:

HMSO.STCDDART, H., MATHEW, D., ATKINSON, S., et al. (1994) Commissioning conferences: a consultative

approach to purchasing. British Journal of Hospital Medicine, 52, No 2/3: 117-119.STRATHDEE, G. & THORNICROFT, G. (1994) The Principles of Setting up Mental Health Services in the

Community. In: Principles of Social Psychiatry (Eds Bhugra, D. & Leff, J.) Oxford : Blackwell.TAKAHASHI R., SAKUMA, A., ITO, K. et al. (1975) Comparison of efficacy of Lithium Carbonate and

Chlorpromazine in mania. Report of Collaborative Study Group on the Treatment of Mania in Japan.Archives of General Psychiatry, 32, 1310-1318.

TAYLOR, P. (1986) Psychiatric disorders in London’s life sentenced prisoners. British Journal of Criminology,26, 63 78.

TURNER, T.. NESS, M. & IMISON, C. (1992) Mentally disordered persons found in public places.Psychological Medicine, 22, 765-774.

WESTERMEYER. J. (1991) Working with an interpreter in psychiatric assessments. Journal of Nervous andMental Disease, 178, 745.

WILSON, M. (1993) Mental Health and Britain’s Black Communities. NHS Management Executive: MentalHealth Task Force & Kings Fund Centre.

WINETT, R., KING, A. & ALTMAN, D. (1989) Health Psychology and Public Health. London: PergamonPress. London.

YAMASHITA, I. (1992) Transcultural psychopharmacology. Psychiatric Bulletin, 16, 732-733.



256

Dr. Kamaldeep Bhui, Senior Registrar, The Maudsley Hospital, Denmark Hill, London SE5 8AZ, EnglandYvonne Christie, Independent Advisor (formerly with the King’s Fund Centre and NHS Task Force on Raceand Mental Health), AveLeon Associates, 110 Perry Hill, London SE6Dr. Dinesh Bhugra, Senior Lecturer, Institute of Psychiatry, De Crespigny Park, London SE5 8AF

Correspondence to Dr. Bhui



The Essential Elements of Culturally Sensitive Psychiatric Services

Documents

Transcript of The Essential Elements of Culturally Sensitive Psychiatric Services