Venue: Online
Date: Thursday, 15th July 2021
Time: 18:00

Speakers

• Sue Liburd MBE DL, Non-Executive Director, NHS Lincolnshire Clinical Commissioning Group
• Shuranjeet Singh, The Founder, and Director of Taraki
• Prof Kamaldeep Bhu, Professor of Psychiatry and Hon Consultant Psychiatrist at University of Oxford; Editor-in-chief, British Journal of Psychiatry
• Hannah Lowe, Research Fellow, Dialogue Society

Abstract

The final panel discussion in our series on racial equality will take place on Thursday, 15th of July, at 6pm. As part of this series on racial equality, this Thursday’s discussion is on “The Implications of Racism on Mental Health: Overcoming Structural Obstacles”. This panel discussion aims to explore the relationship between mental health and racism through a structural and institutional lens to uncover the factors that lead to negative mental health consequences for BIPOC and how best to address these issues.

It is now widely reported that experiencing racism can lead to negative mental health consequences, with research showing that the group with the highest score for severity of mental health symptoms, Black British adults, are also the least likely to receive treatment.

So what are some of the factors that lead to negative mental health consequences among BIPOC? What are the structural barriers that prevent BIPOC from accessing mental health treatment and how do we ensure effective treatment is accessible, particularly to the most vulnerable groups?

As the final part of a series aiming to highlight the multi-faceted and layered dimensions of racism, we are excited about this challenging, engaging, and important discussion. Ultimately this discussion aims to emphasise positive approaches in working towards the goal of racial equality and highlight suggestions for decision-makers on how best to make positive changes.

We are very excited about what is hopefully just the beginning of a focus on important topics and issues that we plan to continue to address this year. We would be very happy to see you participate in these virtual events, which you can watch on our YouTube channel and join in the discussion with your comments and questions.

We are looking forward to seeing you online.

Highlights

Sue Liburd begins by outlining some of the uncomfortable truths concerning mental health and racism, initially highlighting that racism is a stressor that long term, can affect our mental health with day-to-day indignities becoming cumulative. This is then combined with the reality that social determinants disproportionately impact ethnic minorities. Sue describes social determinants as the conditions in which people are born, grow, were educated and live. The social situations and environments can impact us throughout our lives, for example, housing, education, access to affordable food, and good nutrition. Sue then highlights that there are high levels of health inequality and health disparities that impact ethnic minorities compared to other groups. Therefore, minority communities are at higher risk when regards to mental health.

Furthermore, the experience of ethnic minorities has of mental health services is different from those of other groups, leading to poorer outcomes. Similarly, Sue emphasises the barriers that people face in accessing services. The uncomfortable truth is that minority communities are comparatively at higher risk of poor mental health, having social determinants that impact people over a long time and leave them more likely to present with chronic physical and mental illnesses while also finding barriers in accessing suitable treatment.

Sue then focuses on challenges minorities experience both in accessing services, the treatment phase and the recovery phase. When looking at the access phase, minorities are less likely to access mental health support in primary care. Secondly, 40% less of ethnic minorities, mainly the black community, access services via the criminal justice system compared with white people. This is an uncomfortable statistic. Sue then highlights social determinants that become barriers to people accessing mental health services, such as immigration status, language barriers, lack of access to information. Sue states that these determinants can act as deterrents and restrict access to those services.

Sue then focuses on the assessment phase, stating that because of barriers to access, ethnic minorities often access late and therefore may have poor physical health conditions alongside mental health illnesses. This causes doctors to focus on the physical condition, which, though absolutely necessary, the challenge is to avoid clinician bias where the mental health causes may be overlooked. Indeed, mental health impacts and can complicate physical health. Therefore, Sue states that assessment has some bias built into the process that can leave minorities not being treated for mental health issues like other groups in society.

Moving on to explore the treatment phase, Sue states that inequalities persist. Firstly, the treatment experience can have an impact on how people recover. Indeed, because of challenges to accessing services and bias in the assessment phase, Sue argues that crisis management and treatment are more common for minorities, with a bias towards medication instead of talking therapies. We, therefore, see inequalities in the treatment phase.

Lastly, Sue stresses that the experience people have during treatment can have an impact on their recovery, adding that when deciding what can be done to improve mental health services for ethnic minorities, it is crucial to explore the experiences that people have with mental health treatments, through the lived experiences that people share. Furthermore, Sue highlights that such lived experiences impact upon levels of community distrust and uncertainty towards whether or not people should attempt to access services, to begin with. Another challenge Sue highlights is the Eurocentric bias of our health care system, which is a bias towards the majority to the detriment of the minority. This results in low cultural intelligence in terms of mental health service provision.

Finally, suggesting ways to improve the provision of mental health care to ethnic minorities, Sue states that commissioning is critical. In commissioning and designing services, the NHS must consult with service users; therefore, ethnic minorities need to ensure their voices are heard by giving feedback. It is equally vital for the system to reach out to minority communities and ensure that their voices are heard during the process of commissioning and designing services. Sue states that it is incumbent on the health service to look at the broader aspect of recovery, including complementary therapies, meditation and culturally sensitive practices that can mitigate against the Eurocentric bias in the NHS. Sue concludes by posing the option of matching minorities who present to the system with a buddy who genuinely understands the cultural, linguistic or racial identities that service users identify with. She also emphasises the need to give more attention to the provision of culturally appropriate advice and support.

In summary, there are challenges for ethnic minorities in accessing mental health support at every stage, and it is incumbent on mental health providers to be better educated, informed, and more culturally aware. Sue argues that it is also incumbent on us as citizens to make our voices heard as individuals and as communities.

Professor Bhui begins by stressing the difficulty of talking about race, with people tending to fear conflict, highlighting the importance of finding ways to share knowledge and information and have difficult conversations about racism. Professor Bhui states that listening to people and their lived experiences is a powerful way to capture all the complicated nuances that are not usually available from a distance.

Professor Bhui then echoes Sue Liburd in reasserting that racism is associated with mental illness and poor mental health, with egregious acts of racism and violence being hurtful and upsetting. Such experiences for children are seen as adverse childhood experiences, with the more a child is exposed to, the likelihood that their neurodevelopment and educational experience will be affected. It also increases a child’s chances of suffering from poor health. Professor Bhui highlights that if a child has more than six to eight adverse childhood experiences, their life expectancy will be shortened by almost twenty years. This matches the research on trauma, with trauma being associated with poorer physical and mental health across all the diagnostic groups.

Professor Bhui then focuses on the higher incidences of psychosis and schizophrenia in ethnic minorities and migrants, stating that some believe it is a natural phenomenon and part of the natural history of the disease; however, he argues against this, saying that it is crucial to understand the political structures and adversities, including adverse childhood experiences of discrimination that contribute to this. Furthermore, social determinants and their distribution are essential, compounded by the additional factors experienced by minorities, such as racism and discrimination in the workplace and education.

Thirdly, Professor Bhui explores the pathways that people take to receive care, with decades of research showing that ethnic minorities appear to come into contact with services through crises, through the police or criminal justice system, adding that there is a criminalisation of ethnic minorities who are mentally ill. The evidence from first episode cohort studies researching the development of psychosis is that ethnic minorities appear not to be very different from other groups in terms of substance abuse and violence. Moreover, Professor Bhui asserts that ethnic minorities receiving mental health care or treatment are more likely to receive compulsory treatment such as medication rather than psychological therapies and three to four times more likely to be cared for under a mental health act section. While adverse early life events will lead to poorer outcomes, Professor Bhui emphasises the need to prevent these poorer outcomes.

Moving on to suggest the cause for these higher rates of mental illness among ethnic minorities, Professor Bhui highlights social determinants, adverse childhood experiences, educational exclusion and school experience, along with environmental deprivation, poverty and clustered disadvantages. Evidence suggests that these inequalities are not simply about ethnicity but are also impacted by ethnic minority groups living in places of cluster disadvantage and therefore being exposed to multiple unsafe environments, including discrimination and violence. This produces an endemic where numerous complex interacting risk factors over a lifetime lead to these poorer outcomes, which Professor Bhui argues is the only plausible explanation he has come across which might explain the high rates of psychosis in ethnic minorities. Therefore, it is necessary for services to acknowledge these contributing factors and to unpack these structures.

Lastly, Professor Bhui explores the definition of structural disadvantage and the best ways to tackle it. As an invisible barrier that some do not want to or have never had to acknowledge, structural disadvantage becomes dominated by people in these positions of power who are not themselves affected. We, therefore, all must be highly self-aware, constantly self-auditing and questioning the processes and actions that we see around us to monitor practices and procedures. Professor Bhui adds that currently, service commissioning is not mainly organised around people, with there being a trade-off between efficiency versus achieving equity, personalising services, and being flexible and responsive to the needs of people. Indeed, as products of a particular political economy, Professor Bhui adds that this process is not straightforward as commissioning often happens in a particular climate where adversarial conflict is the only way to solve a disagreement, much like we see in Parliament. Therefore, we need more of a truth and reconciliation process to identify and unpack those problems of inequality and an ability to do so with kindness. Ultimately, it has to be a collective action by everyone.

Shuranjeet Singh begins by outlining his motivation for founding the organisation Taraki, which works alongside the Punjabi community to reshape approaches to mental health. Shuranjeet shares personal experiences of transitioning from home to university and the mental health challenges he encountered during his time at university, where he felt that his religion and ethnicity presented racialised challenges. After these experiences of exclusion at university, he became aware of the lack of support for people within his community. The crux of the issue he experienced was related to ostracisation, much of which was interlocked with experiences of racialisation. The approach of Taraki is therefore based on an anti-racist tenant.

Shuranjeet highlights the reality that racism and racist structures are present in research and the lived experience sector. Indeed, Shuranjeet experienced Taraki being invited to participate in research and studies, only to become aware that they did not have a seat at the table. Instead, they were treated as objects of study or vessels from which knowledge was taken and not used to benefit their community. In response to this, Taraki decided to conduct their research around how the Punjabi community has supported themselves during the pandemic, finding that 40% of respondents had been using faith and faith-based practice to support themselves. Indeed, the role of faith in improving mental health is often excluded from the research landscape, and Taraki were able to formulate research that best reflected the reality of the Punjabi community because they were the drivers of the research. This allowed an evidence-based to be created and driven by the communities they work with, where they could centre the voices of people in their communities and understand the complexities within Punjabi communities.

Shuranjeet then goes on to explore the lived experience landscape. Stating that the importance of experiential knowledge is often highlighted, Shuranjeet notes that the lived experience landscape is not neutral. It is not automatically inclusive to all people, with Shuranjeet arguing that there is a massive gap in understanding how racial structures and other types of oppression and discrimination function within the lived experience landscape.

To summarise, Shuranjeet argues that the focus should shift towards equity over equality, where we think about how to work with communities who are systemically disadvantaged when it comes to patient public involvement to build capacity and skills and share knowledge.

About Racial Equality Panel Series

Dialogue Society is pleased to announce a new online panel series on racial equality aiming to highlight the multi-faceted and layered dimensions of racism and how this negatively impacts society. Moving from individual experiences to the impact racism has more broadly in our workplaces, politics, and culture, this panel series aims to focus on positive approaches that work towards the goal of racial equality.

The series has three panels, each one focusing on a particular theme:

1. Fostering Inclusive Workplaces – 27 May
2. Racism across the Diaspora: Personal Narratives from South Africa, USA & UK – 24 June
3. The Implications of Racism on Mental Health: Overcoming Structural Obstacles – 15 July

The first panel will discuss the importance of truly inclusive workplaces, what this means in practice across a range of sectors, and how such an environment can best be fostered.

The second panel will create a space for personal narratives to be shared between individuals from the UK, South Africa, and America. As three states with distinct racial histories, this panel intends to shine a personal light on the impact of historical and political racism that pervades the lives of BIPOC, as well as provide the groundwork for a comparative case study.

The final panel highlights the correlation between racism and mental health, exploring this issue through a structural and institutional lens to uncover the factors that lead to negative mental health consequences of racism for BIPOC. This panel will also emphasise the barriers that prevent BIPOC from accessing mental health treatment and aim to highlight how effective treatment can become more accessible to the most vulnerable groups.