Delivering race equality in mental

health care: report on the findings

and outcomes of the community
engagement programme 2005-2008
Jane Fountain and Joanna Hicks

SUMMARY REPORT 2010

International School for Communities, Rights and Inclusion (ISCRI)

University of Central Lancashire
 contents

Executive summary 02

Introduction 06

SECTION 1:
Delivering Race Equality and the NIMHE Community Engagement project 07
1.1 The ISCRI Community Engagement Model 07
1.2 The NIMHE Community Engagement Project 07

SECTION 2:
Key themes and findings 10
2.1 Fear of mental health services 10
2.2 Effective therapies and interventions 10
2.3 Culturally appropriate treatment 12
2.4 The journey towards recovery 16
2.5 Service user and carer satisfaction with mental health services 17
2.6 A more active role for Black and minority ethnic communities and service users 19

SECTION 3:
Project outcomes 20
3.1 Outcomes for the community researchers 20
3.2 Outcomes for community organisations 21
3.3 Outcomes for Black and minority ethnic communities 21

SECTION 4:
Recommendations from the community organisations 23
4.1 Fear of mental health services 23
4.2 Effective therapies and interventions 23
4.3 Culturally appropriate treatment and interventions 24
4.4 The journey towards recovery 25
4.5 Active involvement of BME communities, service users and carers 26

SECTION 5:
Delivering Race Equality – Some reflections 27

SECTION 6:
References 28

1
EXECUTIVE
section
SUMMARY

1
This is a summary of the full project Studies focused on five of the DRE
report, which can be accessed on characteristics:
www.uclan.ac.uk/iscri/index.php • less fear of mental health services among

BME communities and service users

Launched in 2005, Delivering Race Equality in
• a more balanced range of effective therapies,
Mental Health Care (DRE) (Department of Health,
such as peer support services and
2005) was a five year action plan for achieving
psychotherapeutic and counselling treatments,
equality and tackling race discrimination in
as well as pharmacological interventions that
mental health services in England.
are culturally appropriate and effective
DRE required NHS services to deliver on three • a workforce and organisation capable of

key aims by 2010: delivering appropriate and responsive mental

• equality of access health services to BME communities
• equality of experience • more BME service users reaching

• equality of outcomes.
The action plan was founded on three
building blocks:
• more appropriate and responsive services
• community engagement
• better information.
Initially, DRE was delivered by the National
Institute for Mental Health in England (NIMHE)
and then by the National Mental Health
Development Unit (NMHDU), which replaced
NIMHE in April 2009.
The NIMHE Community Engagement Project was
established by NIMHE within the DRE community
engagement building block. The project was
commissioned from the International School for
Communities, Rights and Inclusion (ISCRI) at the
University of Central Lancashire (UCLan) and
used the ISCRI Community Engagement Model
(Fountain, Patel and Buffin, 2007). This model
brings Black and minority ethnic communities
and public service agencies together to research
and address issues of mutual concern.
self-reported states of recovery, and
• increased satisfaction with services.
The total sample size was 6,018 people,
comprising 5,751 community members and
267 mental health service providers. Of the
community members, 935 (16.2%) currently
used or had used mental health services and
344 (6%) described themselves as carers for
a person with a mental health condition.
Of those identified by their ethnic group,
40% were Asian or Asian British; 24% were
Black or Black British; 17% were White or Other
White; 7% were Chinese; 4% were categorised
as Mixed, and 8% were categorised as Other –
including Cypriot, Iranian, Kurdish, Turkish,
Turkish Cypriot, Vietnamese and Yemeni.
The authors thank Catherine Jackson for her
assistance with the preparation of this summary
report.

The NIMHE Community Engagement Project

For further information on any
aspect of this report, contact
jfountain1@uclan.ac.uk
or iscrioffice@uclan.ac.uk
was conducted in three phases over three
years, 2005-2008. A total of 80 projects were
selected across all eight Strategic Health
Authorities, and 79 community engagement
studies completed: 11 in the pilot phase
2005-2006; 29 in the 2006-2007 phase,
and 39 in 2007-2008.

2
Heading
This review looks back at DRE’s work as its five year plan comes to an end.
DRE has carried out an extensive programme of work and this review
describes some of our key challenges, successes and learning. It also
outlines how DRE’s work will be taken forward under New Horizons.
Findings
Fear of mental health services
Not all participants who were asked expressed
a fear of mental health services. However,
fear as a barrier to accessing services was
a recurring theme in the majority of the
study reports. Those with little or no personal
experience of mental illness reported that their
biggest fear of seeking help was the stigma,
shame and social repercussions. Those who
had direct experience of services, particularly
as inpatients, reported that their biggest fear
was re-engaging with these services. They were
particularly fearful of medication and hospital
admission, of being sectioned under the
Mental Health Act 1983, of being mistreated
by services, that their confidentiality would
not be respected, and of their symptoms and
illnesses becoming worse through contact
with other service users.
Effective therapies and interventions
Study participants and the community
organisations strongly criticised what they
perceived to be an unbalanced reliance on
medication, with its unwanted side effects.
The majority of the mental health service users
who had been treated only with medication
felt that other and/or additional therapies
would have made their treatment more
effective. However, it was reported that
a choice and/or a combination of therapies
were not routinely offered to service users.
EXECUTIVE
SUMMARY
Talking therapies were most often cited as
the preferred alternative to, or accompanying
treatment with, medication although some
concerns were also expressed about
confidentiality and the need for cultural
competence. A minority of the study participants
with mental health problems, across all the
ethnic groups, had used complementary
therapies and wanted them to be available
in mainstream mental health services.
Social interaction and taking part in activities
were thought to maximise the benefits of
prescribed treatment. Services from voluntary
and community organisations were particularly
valued for the opportunities they offered
for socialising, befriending and participation
in activities such as outings, lunch clubs,
exercise and discussion groups.
Culturally appropriate
treatment and interventions
Reports from across all the studies and all
the participating Black and minority ethnic
communities point to a strong need for
greatly increased cultural competency in
mental health services.
Study participants highlighted the need
for practical improvements in language
(interpreting, translating, literacy support),
meeting faith-related and religious needs,
culturally appropriate food, gender-specific
services and staff, increasing the ethnic
diversity of staff, and action to tackle racism.
3
EXECUTIVE
section Heading
SUMMARY

1 This review looks back at DRE’s work as its five year plan comes to an end.
DRE has carried out an extensive programme of work and this review
describes some of our key challenges, successes and learning. It also
outlines how DRE’s work will be taken forward under New Horizons.

The journey towards recovery Outcomes

Factors that facilitate recovery were identified
as support from family and friends, ‘keeping
busy’, a positive attitude, faith and religion,
and medication. Lack of support from family
and friends, the stigma of mental illness, a return
to an unchanged environment after treatment,
a poor experience of treatment, and disbelief
that recovery is possible were seen as obstacles
to recovery.
Service user and carer satisfaction
with mental health services
Levels of satisfaction with mental health
services were highly individual and subjective,
but also inextricably linked to service users’
fears of mental health services, perceptions of
the effectiveness of the treatment received,
experiences and perceptions of services’ cultural
competence, and whether or not they felt their
treatment resulted in recovery.
Positive outcomes were reported for the
individuals and community organisations
involved in the project, and for local
communities. Of 72 CDWs who were
aware of the project, 40% reported seeing
improvements in local mental health
services as a result of the community
engagement studies.
The most frequently reported improvements
included better awareness and understanding of
mental ill health, improved community contacts
and community engagement, better services
and information, and improved communication
and contact with commissioners. The most
frequently mentioned obstacles to achieving
improvements were lack of funding and lack
of support from healthcare professionals and
senior NHS management.

There were many accounts and much statistical

data showing that services had made a positive
impact. Equally, there were some powerful
stories of problematic experiences. As one of
the community organisations commented:

‘Where someone’s illness was explained

and understood... and a choice of treatment
offered, people, in general, had a much
better perception of the mental health
services provided.’

A more active role for Black and

minority ethnic communities and
service users
The NIMHE Community Engagement Project
of itself enabled a more active role for Black
and minority ethnic communities and Black and
minority ethnic service users, in that so many
community members and organisations were
actively involved in the studies and in identifying
barriers and opportunities for improving service
accessibility and provision.

4

Recommendations
The majority of the studies recommended vastly
increased involvement of Black and minority
ethnic community members and service users
in the planning, commissioning and delivery
of mental health services. This would reduce
these communities’ fear of mental health
services; provide them with a more balanced
range of culturally appropriate, effective
therapies; increase mental health services’
cultural competence; increase self-reported
recovery rates among Black and minority ethnic
service users and increase their satisfaction
with services.
Taken together, the study reports proposed a
very wide range of detailed recommendations
to meet the DRE aims and vision. These can be
summarised as:
• more training and proactive recruitment
of Black and minority ethnic people, so that
they are represented at all staffing levels
within mental health services
• more community-based services, staffed
and run by members of the target community
• more service user input into
planning services
• more service user input into
advocacy services
• increased input by Black and minority
ethnic community members (including
mental health service users) into cultural
competency training for all mental health
service staff, including all those who treat
service users and come into contact with
them (such as receptionists) and for those
who may need to be more aware of
providing culturally appropriate services,
such as interpreters and chefs
• support to Black and minority ethnic
community organisations and members
(including mental health service users) to
provide information to their communities
about mental health and mental health
services, in order to address stigma and
encourage help-seeking
EXECUTIVE
SUMMARY
• e ncouragement to service users and
other community members to set up
self-help and peer support groups
both to support each other and support
general mental wellbeing
• more funding for community
organisations to provide opportunities
for social interaction and a range of leisure,
educational and occupational activities
• partnerships between mental health service
providers and religious and community
organisations to increase all parties’
knowledge and awareness of mental health
service needs in terms of faith and religion
• recruitment of Black and minority ethnic
chefs to work in mental health services
providing food
• recruitment from the local community
of bilingual workers, interpreters,
community workers, outreach workers,
ambassadors, advocates and champions
to act as links between mental health
services and the community
• opportunities for service users to
volunteer at the mental health services
they attend, to enhance confidence and
provide a pathway towards work, and
• services to encourage peer support to
service users via mentoring and befriending.
Importantly, the study reports also highlight
the need for local action involving local
communities. As the studies show, beneath the
broad consensus on the key issues of cultural
competence and mistrust of mental health
services, the needs and priorities of the various
Black and minority ethnic communities in
England vary widely. Blanket solutions are
not appropriate: what works for any one
Black and minority ethnic community may be
inappropriate and unacceptable for another.
5
section
INTRODUCTION DRE – A FIVE YEAR ACTION PLAN
1 Launched in 2005, Delivering Race Equality
in Mental Health Care (DRE) (Department
of Health, 2005) was a five year action plan
for achieving equality and tackling race
discrimination in mental health services
in England.
The plan emerged partly in response to growing
disquiet at the disproportionate number of Black
African and Black Caribbean men detained in
psychiatric hospitals in England under the Mental
Health Act 1983. DRE was produced following
the inquiry into the death, while under restraint
in an NHS psychiatric unit, of a African Caribbean
man, David Bennett, in 1998 (Norfolk, Suffolk
and Cambridgeshire Strategic Health Authority,
2003). However the action plan extended its
remit more widely to encompass all ethnic
groups in England, including migrants from
Central and Eastern European countries,
Irish people and Irish Travellers.
DRE required NHS services to deliver on three
key aims by 2010:
• equality of access
• equality of experience
• equality of outcomes.
The five year vision for DRE was that, by 2010,
mental health services should be characterised by:
• less fear of mental health services among
Black and minority ethnic (BME) communities
and service users
• increased satisfaction with services
• a reduction in the rate of admission of
people from BME communities to psychiatric
inpatient units
• a reduction in the disproportionate rates of
compulsory detention of BME service users
in inpatient units
• fewer violent incidents that are secondary
to inadequate treatment of mental illness
• a reduction in the use of seclusion in
BME groups
• the prevention of deaths in mental health
services following physical intervention
• more BME service users reaching self-reported
states of recovery
6
•  a reduction in the ethnic disparities found
in prison populations
• a more balanced range of effective therapies,
such as peer support services and
psychotherapeutic and counselling treatments,
as well as pharmacological interventions
that are culturally appropriate and effective
• a more active role for BME communities
and BME service users in the training of
professionals, in the development of mental
health policy, and in the planning and
provision of services, and
• a workforce and organisation capable of
delivering appropriate and responsive mental
health services to BME communities.
The action plan was founded on three
building blocks:
• more appropriate and responsive services
– through action to develop organisations and
the workforce, to improve clinical services and
to improve services for specific groups, such as
older people, children and adolescents,
and asylum seekers and refugees
• community engagement – through
healthier communities and by action to
engage communities in planning services,
supported by 500 new community
development workers (CDWs)
• better information – through improved
monitoring of ethnicity, better dissemination
of information and good practice, and
improved knowledge about effective
services, including an annual census of
mental health inpatients.
To achieve these aims, 17 focused
implementation sites (FISs) were established
across England to pioneer best practice in
eliminating discrimination in mental health
care. Regional race equality leads (RELs) were
also appointed to provide local leadership for
the Department of Health and NIMHE’s Black
and minority ethnic programmes, including the
DRE action plan.
One of the methods of fulfilling the community
engagement agenda was to use the ISCRI
Community Engagement Model.
DRE and THE NIMHE Community
Engagement Project
The Community Engagement Project was
established by NIMHE as one of the initiatives
within the DRE community engagement
building block. It aimed to:
• help to build capacity in the non-statutory
sector
• encourage the engagement of Black and
minority ethnic communities in the
commissioning process
• ensure a better understanding by the
statutory sector of the innovative approaches
used in the non-statutory sector
• involve Black and minority ethnic
communities in identifying needs and in the
design and delivery of more appropriate,
effective and responsive services
• ensure greater community participation in,
and ownership of, mental health services
• allow local populations to influence the
planning and delivery of services
• contribute to workforce development and
specifically to the recruitment of 500
community development workers.
To achieve these aims, it adopted a model of
community engagement originally developed
by the Centre for Ethnicity and Health at the
University of Central Lancashire (UCLan).
section
1
1.1 The ISCRI Community
Engagement Model
The ISCRI Community Engagement Model
(Fountain, Patel & Buffin, 2007) (ISCRI,
the International School for Communities,
Rights and Inclusion, is the successor to the
CEH) takes as its starting point the premise that
the community itself is best able to access its
own members in order to raise awareness and
assess need. It brings communities (individuals
and organisations) and agencies together to
research and address issues of mutual concern
and ensure that the findings from the research
benefit the communities that are being studied.
Individuals from the target community are
recruited and provided with training and
support from an external facilitator (UCLan
in this case) to conduct the work. Close
involvement of the public agencies responsible
for commissioning, planning and delivering
public services agencies is seen as essential
to the success of the projects. This is ensured
by their representation on the project
steering group.
1.2 The NIMHE Community
Engagement Project
The NIMHE Community Engagement Project
was conducted in three phases over three years,
2005-2008. Applications were sought from
local community organisations to host the
community engagement studies. A total of
198 applications were received over the three
years, 80 were selected and 79 community
engagement studies were completed: 11 in the
pilot phase 2005-2006; 29 in the 2006-2007
phase, and 39 in 2007-2008. Altogether,
75 community organisations were involved
(four each conducted two studies and one
community organisation was unable to
complete the work).
7
 section DRE and THE NIMHE Community
Heading
Engagement Project

1
continued
This review looks back at DRE’s work as its five year plan comes to an end.
DRE has carried out an extensive programme of work and this review
describes some of our key challenges, successes and learning. It also
outlines how DRE’s work will be taken forward under New Horizons.

Table 1: In several cases, partnerships between community 1.2.2 Data collection

Breakdown of community organisations were formed especially for the
engagement studies by project. Local branches of national organisations
Strategic Health Authority also conducted some studies. In some instances,
close alliances were formed with DRE CDWs
SHA area Studies
and, in a few cases, CDWs played a lead role in
East of England 5 managing the community engagement team
East Midlands 8 and/or gathering data for the study.
London 17 The vast majority of the studies were conducted
North East 2 within designated DRE FISs and all ten strategic
North West 12 health authority (SHA) areas were represented
(see table 1).
South Central 6 focus groups (32 studies), case studies (seven
South East Coast 3 1.2.1 The themes
Community organisations were asked to actively
South West 8
engage members of Black and minority ethnic
West Midlands 11 communities (including mental health service
Yorkshire and 7 users), both as researchers and study participants,
the Humber in researching one or more of the 12 service
characteristics set out in the DRE vision.
The community engagement studies focused on
five of the DRE characteristics:
• less fear of mental health services among BME
communities and service users
• a more balanced range of effective therapies,
such as peer support services and
psychotherapeutic and counselling treatments,
as well as pharmacological interventions that
are culturally appropriate and effective
• a workforce and organisation capable of
delivering appropriate and responsive mental
health services to BME communities
• more BME service users reaching self-reported
states of recovery, and
• increased satisfaction with services.
A total of 547 community researchers were
recruited by the 75 community organisations to
collect data for the project. They comprised 331
(61%) females and 216 (39%) males. Of these,
48 (9%) were previous or current mental health
service users and nine were carers of service users.
A variety of research methods were used to
collect data from community members. Many
studies used more than one method. They
included face-to-face interviews (77 studies),
self-completion questionnaires (five studies),
studies), events and seminars (nine studies)
and a video diary (one study).Two studies used
clinical evaluation tools (the PHQ9 screening
tool for assessment of depression and Clinical
Outcomes in Routine Evaluation (CORE)).
A variety of methods was used to collect data
from service providers, including self-completion
questionnaires, and focus and discussion groups.
Core demographic information was obtained using
questions devised by the Centre for Ethnicity and
Health’s community engagement team.
In addition, a year after the project ended, a short
questionnaire was devised for DRE CDWs to
gauge their levels of involvement in the NIMHE
Community Engagement Project, whether they
had seen any improvements to mental health
services as a result, and if there were any
obstacles that prevented these improvements.
The questionnaire was administered online
using SurveyMonkey, a tool that also analyses
the results.

A sixth characteristic, ‘a more active role for

Black and minority ethnic communities and Black
and minority ethnic service users in the training
of professionals, in the development of mental
health policy, and in the planning and provision
of services’, was also explored by the authors of
this report, based on the study outcomes.

8

1.2.3 Participants
The total sample size was 6,018 people,
comprising 5,751 community members and
267 mental health service providers.
1.2.4 Community sample
Of the 5,751 community members, 935
(16.2%) reported that they currently used,
or had used, mental health services and 344
(6%) described themselves as carers for a
person with a mental health condition.
However not all the community members were
asked if they were service users or carers, so
these figures may be an under-representation.
The sample’s ages ranged from 16 to over 80.
The sample comprised a wide range of
ethnicities. Some studies focused on just
one ethnic group; others included a variety.
A total of 4,888 people (85% of the
community member sample) stated their
ethnicity (see figure 1):
• A sian or Asian British (1,955/40%) –
predominantly South Asian (Pakistani (904),
Indian (580) and Bangladeshi (249)).
The remainder described themselves as
Other Asian or Asian British
• Black or Black British (1,173/24%) – mainly
Black Africans (726) and Black Caribbeans
(381). The remainder categorised themselves
as Other Black or Black British
• White and Other White (831/17%) –
including Romany Gypsies (204), Irish
Travellers (78), Gypsies and Travellers (141),
Irish (179), Ashkenazi Jewish (50), and
Polish and other Eastern European people
• Chinese (342/7%)
• Mixed (196/4%) – mainly White and Black
African or White and Black Caribbean
• O ther (391/8%) – including Cypriot, Iranian,
Kurdish, Turkish, Turkish Cypriot, Vietnamese
and Yemeni.
section
Approximately a third of the community
1
Figure 1:
member sample had been born in the UK.
Ethnicity of community
Of those who said they had been born
sample participants
elsewhere, almost half had lived in the UK
for 11 years or longer; 15% had lived in the 391 (8%)
UK for between six and ten years; just over 196 (4%) 1,955 (40%)
25% had lived in the UK for between one and 342 (7%)
five years, and the remainder (less than 10%)
had lived in the UK for less than one year.
More than two thirds of the 4,817 people 831 (17%)
(84% of the community member sample) who
reported their citizenship were British citizens.
1,173 (24%)
The community member sample reported
using a total of 131 languages and dialects Asian or Asian British
as either their first language or those that
they spoke and/or wrote fluently. The majority Black or Black British
said English was the language they most often
White and Other White
spoke or wrote fluently, but some studies noted
that study participants may have overstated Chinese
their proficiency.
Mixed
Of the 5,156 (90%) of community members
who reported their faith or religion, the largest Other
proportion were Muslim (46%), followed by
Christian (29%). Smaller proportions reported
that they were Hindu (5%), Sikh (5%), Buddhist
(3%) and Jewish (2%), and 6% said they had
no faith or religion. The remaining 4% included
people who reported their faith or religion as
Ancestor Worship, Jain or Rastafarian.
Nearly a third of the sample declined to state
their sexuality. Of those who did, the vast
majority were heterosexual, three were
lesbians and 12 were gay men. Ten people
reported that they were bisexual.
1.2.5 Service provider sample
Sixteen community organisations included
voluntary and statutory sector mental health
service providers and other mental health
professionals in their studies. One comprised
primary and secondary statutory mental health
service providers only. These service provider
representatives totalled 267 people.
9
section Key themes and findings
2
2.1 Fear of mental health services
Fear as a barrier to accessing services was a
constant, recurring theme in the majority of the
study reports. Community members with little
or no experience of mental illness were more
likely to say that stigma, shame and their
repercussions (such as the negative effect on
marriage prospects) would prevent them seeking
help. Those with direct experience of services,
particularly as inpatients, were much more
fearful of re-engagement with services.
A number of studies explored these fears.
They included fear of over-medication; fear of
being sectioned under the Mental Health Act
1983 if they divulged all their mental health
issues and problems to GPs and other primary
care staff; fear of being mistreated by mental
health services, and fear that their confidentiality
would not be respected, in particular in relation
to talking therapies:
‘I would rather talk to my cat than talk to a
counsellor: it’s about trust, at least my cat
isn’t going to talk.’
There was some evidence that fear was not
a major issue for many Arabic-speaking,
Kurdish, Turkish and Yemeni study participants,
particularly males. However, reducing fear of
mental health services was stressed as a
priority in most of the studies.
In most cases people described multiple
fears, with complex connections to their own
experiences and perceptions of services’
cultural competence, especially in relation
to language, faith and religion:
‘I can’t speak English so if I needed to stay
in hospital, what would the food be like,
I wouldn’t be able to speak to the nurses –
I would be very scared.’
Overall, the study participants were more likely
to report fear about services’ lack of cultural
competence than concerns about overt racism.
However, studies of young people found some
negative stereotypes and perceptions of mental
health services:
10
‘Racist people work there and will try and
drug you up.’
Another concern expressed particularly by young
people was the belief, highlighted in several
studies, that future work prospects would be
adversely affected if the jobseeker had a record
of mental health problems.
2.2 Effective therapies
and interventions
2.2.1 Key findings
Study participants and community organisations
strongly criticised a perceived unbalanced
approach to treatment, with an over-reliance
on medication.
‘Man they said I was mad, mad till I was
dangerous… What I say is I not mad, I sad
and pissed off. I don’t have the energy to
do anybody anything… but I was classed
schizophrenic and injected all over the place.’
Some studies – of South Asian women who
had experienced domestic violence and of
Irish Travellers, Gypsies and asylum seekers –
emphasised that, for some, treatment could
never be fully effective because the situation
that contributed to their mental health problems
remained unchanged:
‘Despite using tablets for depression, I do not
feel any relief because I am still experiencing
domestic violence.’
2.2.2 Medication
A majority of the mental health service users,
across all 79 studies, regardless of ethnicity,
reported that the medication prescribed to
them was effective, despite many experiencing
unwanted side effects.
However the majority of the mental health
service users who had been treated only with
medication felt that other and/or additional
therapies would have made their treatment
more effective. It was clear from the studies
that choice and a combination of therapies
were not routinely offered.
 section

2.2.3 Talking therapies
There were far more positive than negative
comments from mental health service users
about the effectiveness of talking therapies
(in both community and clinical contexts,
and regardless of ethnicity, gender and age).
However many study participants qualified their
enthusiasm for talking therapies by stressing
the importance of cultural competence:
‘All I want and need is to talk to a therapist
that shares my culture so that I can unload.
It is easier to talk to someone who knows
and understands the culture.’
Several studies reported that people with
mental health problems placed high value
on family support as an element of effective
treatment and felt that family counselling
would be useful.
A minority of mental health service users
did not see talking therapies as necessary or
effective, and some felt they were culturally
inappropriate, especially Black Africans,
asylum seekers and refugees, and Irish
people, including Travellers. Confidentiality
concerns were also raised.
2.2.4 Complementary and
‘alternative’ therapies
Twenty of the 79 study reports discussed
complementary or ‘alternative’ therapies.
Ten of these were studies involving older
adults, the majority from the South Asian
and Chinese communities.
Participants reported using a range of therapies,
including traditional Chinese medicine,
traditional healing practices, Reiki, Ayurvedic
therapy, acupuncture, massage, meditation and
various occupational therapies, and expressed
a great deal of satisfaction with them.
2
Black African, Black British and Black Caribbean
mental health service users wanted increased
access to music and art therapies, herbal
remedies and swimming and relaxation
therapy, and one study of Somali service
users reported widespread use of ‘traditional
healing’ among this population.
2.2.5 Social interaction and
participation in activities
Social interaction and taking part in activities
were thought by mental health service users to
maximise the effectiveness of their prescribed
treatment. Ex-service users and those who
had never had contact with mental health
services similarly commented on the benefits
for mental wellbeing of formal and informal
socialising and participation in activities.
Mental health support services, peer support
groups and self-help initiatives were regarded
as equally beneficial:
‘For me, it would be more social settings such
as drop-ins, groups, so that it’s a way in to
services without being called a service as
such, so it’s based on a social activity with
the added thing of building relationships,
trust, self-esteem.’
2.2.6 Voluntary and
community organisations
Voluntary and community organisations were
seen as important providers of opportunities
for social interaction because people felt they
could be certain that they would meet others
there who would understand their culture,
language and religion:
‘We come to socialise at the centre for one
day [a week] and it makes us feel good.
There should be more days for us to socialise.
We don’t like sitting at home.’

Overall, around one third of the South Asian

participants in the studies that discussed
complementary therapies thought that
they should be included in a choice of
culturally appropriate treatments for mental
health problems.

11
section Key themes and findings
Heading
continued
2 This review looks back at DRE’s work as its five year plan comes to an end.
DRE has carried out an extensive programme of work and this review
describes some of our key challenges, successes and learning. It also
outlines how DRE’s work will be taken forward under New Horizons.
2.3 Culturally appropriate treatment
2.3.1 Key findings
The need for greatly increased cultural
competence by mental health services was
universally and strongly expressed throughout
all 79 studies. Many did not define ‘cultural
competence’, but the overall message was
very clear: participants wanted their language,
faith and religion and their dietary and gender
requirements to be acknowledged by mental
health service staff throughout their diagnosis,
treatment and aftercare.
Some of the studies’ participants recognised that
it was difficult for service providers to understand
all aspects of their culture. However, as one study
participant pointed out:
‘We understand that we are living in the
UK, but just like we follow their rules and
regulations for things, they need to try to
understand that we cannot change our
culture and tradition because this is what
we have been taught/brought up with.’
Another said simply:
‘The psyche has not changed, it has been
transplanted into a foreign place.’
2.3.2 Language
Language was identified as one of the major
barriers (or, in some reports, as the main barrier)
to accessing mental health services by a large
proportion of service users, carers, community
members and service providers.
There was some evidence that satisfaction with
mental health services was greater among those
who could communicate effectively in English,
those whose service providers spoke the same
language, and those who were satisfied with
their interpreters.
Almost one third of the 79 studies reported that
the inability to speak English was a major factor
in the social exclusion of a large proportion of
their samples, and that this adversely affected
their mental health.
12
The reports identified communication difficulties
throughout the journey through mental health
services, starting from diagnosis:
‘Potentially, difficulties and problems may have
been misunderstood or misrepresented and
this could jeopardise appropriate and effective
treatment. It can also create a barrier to
effective and trusting relationships between
service user and professional.’
A small number of studies highlighted difficulties
associated with literacy problems, such as missed
appointments, not understanding care plans and
failing to take medication correctly.
Studies also highlighted problems with the
cultural and medical terminology of mental
health and mental health services. When the
community organisations translated their
questionnaires into the languages of the
target samples, it was noted that:
‘In many instances, the quality of the responses
significantly improved whenever terms from
the appropriate community language were
used to explain and clarify key concepts.’
A commonly expressed need, across all
ethnicities, ages and languages, was for
jargon-free, simple information about
mental health and mental health services.
Several studies, particularly those among Black
Africans and Black Caribbeans, commented on
a common misunderstanding of the term
‘mental health’:
‘People thought the terms “mental health” and
“mental illness” meant the same thing and
said they referred to people who were not in
their right mind... We found the term “mental
health” was often being used as a short way
of saying mental health problems.’

2.3.3 Interpreting and translating services
Translation and interpretation were seen as
core issues that service providers must address,
in the 60 study reports that included aspects
of language in their investigations.
Although a small minority of study participants
were satisfied with the interpreting and
translating services they had received, the study
reports revealed significant unmet needs,
regardless of ethnicity. These studies also
stressed the lack of information about mental
health and mental health services in languages
other than English.
‘[Current] interpreting services did not
seem to be solving the language difficulty
in using primary and mental health services.
This unmet need has led to frustration,
stress, disappointment and a feeling of
being treated unfairly.’
The lack of availability of interpreters was
commonly reported by the study participants
as a source of worry and concern, and in some
cases it was said to have aggravated their
mental health problems.
Many study participants had little confidence
in the professional interpreters they had
been allocated. There was a very commonly
expressed request for interpreters to be
‘qualified’ and ‘trained’ in mental health
issues and to be familiar with the culture of
the person for whom they were interpreting.
Some study participants did not trust that
their words were being correctly interpreted.
Many mental health service users reported
using family members, friends and contacts
in the community (such as people from
community organisations and places of
worship) to interpret. However some people
did not want to divulge personal information
to a family member, or feared their words
would be deliberately misinterpreted, with the
justification that this was ‘in their best interest’.
Using a family member as an interpreter could
present particular difficulties for South Asian
women who had experienced domestic violence:
section
‘The bad thing was that my English was not
2
good, but they never arranged an interpreter
for me. So every time my husband came and
translated for me. I could not say much.’
Study participants commonly agreed that:
‘We want a service where the workers
understand our language and not have an
interpreter. We want to be able to explain
our own problems.’
2.3.4 Faith and religion
A total of 36 studies explored in varying depths
the spiritual needs of mental health service
users and their experiences of using services.
The vast majority of these studies reported
a lack of awareness among statutory mental
health service providers about faith and
religious needs.
In contrast, voluntary and community
organisations were reported as giving a much
higher priority to faith and religion and their
importance for some Black and minority
ethnic communities. These services were
greatly appreciated.
However some studies stressed that service
providers should not make assumptions about
a person’s religion based on their skin colour
or name:
‘Not everyone who classes themselves as
a Muslim is actually a practising Muslim.
This information would prove important if
setting up services, as assumptions cannot
always be made regarding a person’s
requirements based on their religion –
e.g. not all Muslims require Halal food.’
Many studies stressed the importance of
accommodating religious perspectives with
western models of mental health treatment:
‘I think where service users are spiritual,
it helps them understand their problems
and how they see the world. You can’t
ignore people’s spiritual needs... We need
to build bridges and find solutions.’
13
section Key themes and findings
Heading
continued

2 This review looks back at DRE’s work as its five year plan comes to an end.
DRE has carried out an extensive programme of work and this review
describes some of our key challenges, successes and learning. It also
outlines how DRE’s work will be taken forward under New Horizons.

2.3.5 Food Suggestions included supported housing for

The majority of the study reports included the
provision of culturally appropriate food in their
recommendations aimed at increasing services’
cultural competence. Dissatisfaction with the
lack of culturally appropriate food was expressed
by all ethnicities represented in the studies.
Several studies made the point that this added
to the stress of people who were mentally ill
and in hospital, isolated from their families,
friends and usual activities.
Only one study reported largely positive
experiences. Some service users said they
asked their families to bring meals to them
in hospital or, if they attended day centres,
ate before they went.
2.3.6 Gender-specific services
Sixty-six of the 79 study reports discussed
some aspect of gender, many of them in detail.
These included 39 that addressed the issues
of gender-specific services and staff.
Many of the study participants identified mixed
gender services as a barrier to accessing mental
health services. This was a problem especially,
but not exclusively, for women. These participants
wanted gender-specific mental health services,
and some wanted female-only or male-only areas
within hospitals and treatment centres:
South Asian men with mental health illnesses,
mental health services specifically for Irish men,
because ‘A lot of Irish men get no help’, and
Black Caribbean men’s groups ‘for talking as
men... to help them socially, motivate them,
be therapeutic and give them useful ideas’.
2.3.7 Gender of staff
A majority of study participants who discussed
the gender of staff wanted to be treated by
a mental health professional of the same
gender as themselves, or to have the choice.
This appeared to be more of an issue for
females than for males.
‘Male nurses in hospitals were considered
inappropriate for religious women concerned
about personal modesty and [who had]
limited contact with men other than
husbands and close relatives, such as
fathers and brothers.’
‘Older generations of Asians find talking to
a stranger of the opposite sex “taboo.”’

‘For [Muslim and Orthodox Jewish] women,

being left alone with men can aggravate
[mental] distress further because keeping their
personal space private and away from men is
an essential aspect of their devotional life.’

Several study reports pointed out that mental

health services need to offer childcare if mothers
of young children are to attend.

Need for male-only services was reported in

studies with men from many ethnic groups –
Bangladeshi, Somali, Black Caribbean,
Irish and others.

14

2.3.8 Factors affecting the mental
wellbeing of women
The studies identified a number of cultural
factors that affected the mental wellbeing
of Black and minority ethnic women.
These included isolation, women’s role in
the family, the stigma of mental illness and
of being seen to be ‘not coping’ with their
family responsibilities, powerlessness, violence,
and the asylum-seeking process:
‘My husband used to beat me up all the time,
my in-laws always abused me... I lost my
confidence, I was scared, mentally distressed.
I always had a headache... I could not do
anything properly. I was always crying and
began to consider myself useless.’ (Study on
domestic violence among South Asian women)
Many female asylum seekers expressed
concerns about the effect of their own poor
mental health on their children:
‘Day and night I think about it. I can’t sleep
or look after my children properly. I keep
wondering what I did wrong in my life to
be treated like this. My fear of going back
[to her home country] is huge.’
2.3.9 Factors affecting the mental
wellbeing of men
Almost two-thirds of the community engagement
project’s total sample was female, which may in
part be a reflection of some men’s reluctance to
talk about mental health problems (their own
and others’) and to seek help. For example, in one
study of 100 Black African men, three-quarters
said that they had poor mental health, but the
majority said they would not seek help for it:
‘Because as a black man, I feel if I tell
someone, they will think I am weak.
So we tend to keep it to ourselves.’
A few studies did highlight gender-specific
issues for men. Male asylum seekers from a
wide variety of ethnicities talked about the
impact of seeking asylum on their self-esteem,
and in particular being unable to work:
‘Asylum seeker’s life is disabled life – we
don’t know who we are and we can’t do
anything [work].’
section
Several studies among a variety of ethnic
2
groups discussed how social isolation
negatively affected men’s mental wellbeing:
‘I get out, walk around, see people and keep
myself busy. If I didn’t, I’d be like the other
guys in the hostel [where he lives] who
just sit and get more depressed.’ (Study of
Irish men)
2.3.10 Ethnicity of staff
Most (67) of the 79 study reports explored
participants’ views about the ethnicity of
mental health service staff. This was clearly
regarded as another important element of
a service’s cultural competence.
However, the major expressed need identified
by this project was for mental health services
and staff that are empathetic and sensitive
to cultural and religious needs. Many of the
participants, regardless of ethnicity, gender and
age, argued that this could be achieved if staff
were of the same ethnicity as their patients.
Matching the ethnicity of staff and patients
was especially demanded by service users,
but it also was seen as essential by other
study participants:
‘They should find another black person that
understands a black person [to treat me],
that’s the only way, you know, because I can
relate better to them than I can relate to
a white man.’
However, some – especially Black Caribbeans,
Jews and South Asians – disagreed:
‘Ethnicity isn’t important – it’s the amount
of knowledge they have and how much
support they are going to provide... that is
most important.’
Voluntary and community organisations were
commended for providing services (including
mental health support services) in religiously
and culturally supportive environments, and
a major reason for this was reported to be
because they were staffed by people who
were the same ethnicity and spoke the same
language(s) as those who visited them.
15
section Key themes and findings
continued

2 2.3.11 Racism in mental health services
By no means all the study participants used the
term ‘racism’ (or ‘discrimination’) to describe the
failure by mental health services to address their
language, faith and religious, dietary and gender
needs. As one of the study reports pointed out:
‘... it seems that only direct discrimination is
recognised and that, for example, lack of access
to an interpreter to facilitate engagement is
not identified as discrimination.’
Nevertheless, some study reports were in no
doubt that mental health services’ lack of cultural
competence amounted to institutional racism.
Of the different ethnic groups that participated in
this project, Black Africans and Black Caribbeans
were most likely to refer to racism in mental
health services:
‘As a Black person with a mental health
problem, you’re just walking into a field of
stereotypes. It’s about being big, Black and
dangerous. It’s the known one – it’s the
phrase that people use.’
A smaller proportion of South Asian study
participants used the term ‘racism’ to explain
their negative experiences of mental health
services, even though they felt that their cultural
needs were not being met. One study reported
that this was because South Asians were ‘too
embarrassed’ to complain to the community
researchers about racism.
2.4 The journey towards recovery
Recovery, how it is defined and factors
facilitating and hindering it, were explored
to varying degrees in eight studies.
Factors that facilitate recovery were identified
as support from family and friends, ‘keeping
busy’, a positive attitude, faith and religion,
and medication.
Absence of these factors was seen as hindering
recovery. For example, support from family
and friends was seen as a facilitating factor
when present and as a barrier to recovery
when absent.
Other factors identified as hindering recovery
included the stigma of mental illness, returning
to the same unchanged environment after
treatment, a poor experience of treatment,
and disbelief that recovery is possible.
‘Society stigmas people and if they see
someone with that mental illness
condition I do not think they are so
willing, so accepting, and that is how
I picked up on that prejudice or became
affected by that prejudice and I either
became withdrawn or segregated
myself and realised that I had become
marginalised.’

A minority of participants, across ethnicities and

including White minority ethnic groups, reported
that they were not (or did not expect to be)
treated fairly by mental health services because
of their ethnicity or cultural background.

Racial abuse from other members of the public

was an underlying theme throughout the study
reports. This was reported by all Black and
minority ethnic groups (including the Other White
groups, such as Irish people, Irish Travellers and
migrant workers from Eastern Europe), but
particularly by Muslims and asylum seekers.

16

2.5 Service user and carer satisfaction
with mental health services
2.5.1 Key findings
It is self-evident that levels of satisfaction with
mental health services, as well as being highly
individual and subjective, will be inextricably
linked with the issues, fears and criticisms of
services raised elsewhere in this report.
Fifty-four of the 79 study reports discussed
various aspects of users’ and carers’ satisfaction
with services, although only a minority were
explicitly asked how satisfied they were.
Overall, study participants reported a wide
variety of experiences and levels of satisfaction
with mental health services. There were many
accounts and much statistical data showing
that services had made a positive impact.
Equally, there were some powerful stories of
problematic experiences.
2.5.2 GPs
Levels of satisfaction with GPs varied greatly
between and within studies. Greater
satisfaction was reported where a GP had
referred the patient to secondary care services.
Where a GP prescribed medication only,
there were many reports of dissatisfaction:
‘My doctor’s behaviour was not good…
only medicine is not enough for treatment.’
2.5.3 Medication
As previously reported, some service users’
fear of mental health services centred on what
they saw as a tendency to over-medicate. It was
clear from the study reports that the kind of
medication and the circumstances in which it
was prescribed greatly influenced levels of
satisfaction with mental health services:
‘They lied to me... Convinced me to take the
drug/poison, and then injected it into my
bum... After this, I could not function.’
2.5.4 Religious sensitivity
Several study reports on the Orthodox Jewish
and South Asian communities focused on
levels of satisfaction with mental health
services’ sensitivity to their faith or religion.
section
2
Experiences varied: in one study of South Asian
service users and carers, almost two thirds
of those who had used their GP services felt
they were culturally and religiously sensitive.
However, other studies, especially among
Muslim samples, found much higher levels of
dissatisfaction with services because of their
perceived religious insensitivity. Studies among
Orthodox Jewish communities also reported
dissatisfaction with primary care services
because of their lack of understanding of
religious practices.
2.5.5 Communication
Many of the study reports related satisfaction
levels to the quality of communication and
clarity about the treatment given by services.
Dissatisfaction was expressed in particular
by people who had not had their treatment
explained to them, or whose views were
ignored. As a study report summarised:
‘Where someone’s illness was explained
and understood... and a choice of treatment
offered, people, in general, had a much
better perception of the mental health
services provided.’
2.5.6 Staffing levels
Shortages of staff and lack of time for
appointments, particularly with consultants,
affected satisfaction levels, regardless of ethnic
group. Several studies reported dissatisfaction
with having to see a different member of staff
at each consultation or counselling session,
and having to repeat the same information
at every appointment:
‘With mental health people I didn’t need
every day somebody with a new face...
You get close to her, then the next day
somebody else comes in. It’s painful – you
have to tell your story and how you are
feeling over again.’
2.5.7 Inpatient services
Satisfaction with hospital inpatient services
varied among those who had experienced
them, and was, as highlighted above,
often dependent on a service’s perceived
cultural competence.
17
section Key themes and findings
continued
2 Overall, most people were dissatisfied. Many of
the study participants who were (or had been)
in hospital because of mental illness were there
as a result of a compulsory detention order under
the Mental Health Act 1983. The majority of
these were Black African, Black British or Black
Caribbean. In these circumstances, their level of
satisfaction was low.
In addition, a choice of treatments was not
always offered to those detained under the
Act and these service users reported a high
level of dissatisfaction about their lack of
control over their situation, and the attitudes
and behaviour of staff:
‘No-one spoke to me or helped me work
through my problems in hospital – I was
left to wander around, being offered drugs
by other patients. Staff did not seem
interested in me. The whole experience was
very isolating and scary and I would avoid
ever going to hospital again.’
Feelings of cultural isolation were a recurrent
theme:
‘I don’t talk with [staff or other patients]. I talk
very little. There are no other Chinese patients
here… I just want to leave hospital. This is an
environment for English people.’
However some studies reported high satisfaction
with inpatient services:
‘The best support I’ve received was the
psychiatric care. Things got worse before
they got better and it took me a while to
get the help I needed... [but] I feel better
today, I’ve got things going on and my life
is moving forward.’
2.5.8 Talking therapies
A wide range of satisfaction rates with talking
therapies was reported. As previously highlighted,
satisfaction was strongly related to whether or
not the therapist was perceived as being able to
understand the patient’s culture and, particularly,
communicate in the same language.
18
Some study participants found talking therapies
unhelpful, particularly Black Africans and
some asylum seekers and refugees. One study
report explained:
‘[There is a need for] a clear definition of
counselling as this service is not popular in
Africa. For people to understand the need
of counselling, they first need to understand
what counselling means.’
2.5.9 Complementary and
‘alternative’ therapies
Overall, although only a minority of study
participants had received complementary or
alternative therapies, they were satisfied with
them and preferred them to medication and
talking therapies.
2.5.10 Aftercare services
Study participants expressed dissatisfaction
with the shortage of aftercare services and the
lack of information about them. The following
are representative of many comments:
‘I was not given any information when I
left [hospital]… I didn’t have a clue where
I should turn to, not a clue where I was
supposed to go or who I was supposed
to go to and talk to if I became ill again.’
‘I was kicked out of the system and I had
to fend for myself – I had nowhere to go,
nowhere to live – no care co-ordinator or
CPN [community psychiatric nurse].’
2.5.11 Care plans
Levels of satisfaction with care planning were
not consistent across the study reports but,
overall, a majority reported a lack of satisfaction
– and, indeed, a lack of care plans. Even where
care plans were provided, there were complaints
that people were not involved in writing them.
However a small minority of the study reports
recorded a more positive experience of care
planning, such as a study of Black African,
Black British and Black Caribbean women,
two-thirds of whom said they had been
consulted on their care plans.

2.5.12 Day centres
Satisfaction with day centres was discussed
by only a small minority of the studies.
Two studies, with Irish people and with
older South Asians, reported some positive
experiences of accessing day centres and
satisfaction with being ‘looked after’:
‘It’s good that they have day centres because
when you attend the staff can notice the
warning signs and changing patterns.’
Others disagreed, however:
‘Mainstream [day centres] offer services
that cater mainly for white people, therefore
understanding particular problems of Asians
– i.e. jinn possession/nazar (evil eye) etc will
not be understood.’
2.5.13 Mental health services
provided by the voluntary sector
and community organisations
Voluntary agencies and community organisations
providing mental health services tended to
score highly in satisfaction ratings. Comments
on their mental health services were not as
plentiful as those on statutory primary and
secondary services, but the support and
activities they offered were seen by those
using them as invaluable for maintaining
their mental wellbeing.
2.5.14 Services for carers
Two study reports specifically targeted carers,
but many others included carers in their research
focus and samples. Overall, a total of 344
carers participated in this project and they
were overwhelmingly dissatisfied with services.
As one participant in a study of Black African,
Black British and Black Caribbean carers put it:
‘There is a long way to go before the system
is acceptable to Black African and Black
Caribbean people. No-one takes us seriously,
and we are the ones that know our men best.
We live with them and we know what triggers
them [their mental health problems].’
section
Establishing and building positive working
2
relationships between service providers and
carers was often reported to be problematic.
Frustrations were particularly expressed with
communication between hospitals and service
users’ families.
Several studies reported carers’ difficulties in
accessing support:
‘I had no help or information in the first year.
I didn’t have a social worker or know that
people could help me.’
The issue of carers’ assessments was
highlighted in one report of a study on
dementia. Half of the 78 carers in the study
had been assessed and two-thirds of those
said they were dissatisfied or very dissatisfied
with the outcome.
2.6 A more active role for Black
and minority ethnic communities
and service users
The NIMHE Community Engagement Project
was designed to contribute towards one of
the DRE building blocks, to ensure that Black
and minority ethnic populations have genuine
opportunities to influence mental health policy
and provision, and to promote mental health
and recovery.
This project allowed 547 community
researchers, 75 community organisations,
935 Black and minority ethnic current or
ex-mental service users, 344 carers and
4,472 other community members to contribute
to the development of mental health policy
and to the planning and provision of services.
The project outcomes reported in section 3
below give more details of this achievement
in terms of the outcomes for individuals,
community organisations and communities,
from a variety of perspectives.
19
section Project outcomes
13
3.1 Outcomes for the
community researchers
Community organisations were asked to
complete an exit form at the end of the project.
The form included items about the outcomes for
the individuals who worked on the project as
community researchers. A wide range of positive
outcomes was reported, including enhanced
communication skills; knowledge of mental
health conditions and policies; knowledge
of community research skills; learning about
mental health service user perspectives; project
management skills; building confidence;
Lorna Markland, Community development
worker with Bedfordshire and Luton Mental
Health and Social Care Partnership NHS
Trust, describes her involvement with the
NIMHE community engagement project and
how it has helped local BME communities.
I am currently employed as a Community
Development Worker for Bedfordshire and
Luton helping to deliver race equality in
mental health care.
My journey into mental health work began
when I joined the NIMHE community
engagement programme. I was lead researcher
with my church’s mental health project, Dignity,
in Luton. Dignity conducted one of the initial
pilot projects on mental health needs in 2005/6.
The research has given me a very good
understanding of the issues and the
improvements people wanted to see.
One of the first things I wanted to change
was to demystify the mental health services
among the community. Not enough was
known in the community about services
on offer, so I worked with staff in my mental
health trust to develop the website, create
leaflets and let people in the community
know that there is a range of pathways they
can access to get help.
20
networking and meeting people outside usual
circles; progression to jobs in mental health
work with Black and minority ethnic people,
qualifications from UCLan, and plans to
undertake further study, including degrees
in psychology and social work.
Some of the community researchers were asked
to give short accounts of their experiences in
their study’s report. These also described very
positive personal experiences and outcomes
from the work, as the extract from one of these
accounts, below, shows.
One of the recommendations made in our
community engagement report was that more
links and partnerships should be made between
organisations and the community. Since taking
up my post I have worked on partnership
projects with various organisations such as
Nyabingi service user charity, Mind, the mental
health organisation, and Impact service user
involvement group.
At the moment I am working on improving
cultural competence training within the trust,
and assessing what people really need from
cultural competence training to bring about
positive change for service users. I also hold
a key position within the Trust’s BME Staff
Network. Playing a useful role in tackling
inequalities, especially around ethnicity, is
exactly what I want to be doing. I love my job
and am pleased that I have found a way to
combine my passion with developing a career
in this way.
I am at present looking for a relevant university
course to assist with my progression to the
next level.

3.2 Outcomes for community
organisations
The project’s exit forms also recorded outcomes
for community organisations, including that
some had gained funding for further projects
related to mental health work; presented their
studies’ findings at DRE Local Implementation
Team (LIT) meetings; strengthened their links
with primary care trusts; made connections
with key people in mental health services;
progressed on the implementation of their
studies’ recommendations; and received
continued financial support for projects on
the basis of their studies. In addition, several
community organisations were asked to give
accounts of the outcomes: extracts from one
of these can be found in the box below.
Aap ki Awaaz Project – Rethink, Birmingham
Ajaib Khan, Project Co-ordinator, describes
the Aap ki Awaaz community engagement
project in Birmingham, and what it continues
to achieve.
Rethink put forward a successful application
to conduct a community engagement project
in 2006. The study explored the Pakistani
community’s view of mental health and mental
health services in Birmingham, and was
conducted by a team of 12 members of the
community. We conducted 152 interviews with
members of the community, and held two focus
groups (one with service users and the other
with carers). In addition a self-completion
questionnaire was circulated to 30 service
providers (only seven responses were received).
A number of recommendations are currently
being progressed.
A wide range of initiatives have been
undertaken in partnership with various
organisations. These include provision of
a Mosque roadshow, promoting mental
health awareness and showcasing services
and resources available.
section
3
3.3 Outcomes for Black and
minority ethnic communities
As reported earlier, an online survey was
conducted of the CDWs appointed as part of
the DRE programme to engage communities
in planning services. The aim of the survey was
to obtain their views of the outcomes of the
community engagement project and its impact
within the communities it targeted.
A request (and a reminder) to complete an
online survey was sent to the 419 CDWs on
the NMHDU database in July 2009, and 140
responses (33%) were received.
There has also been a substantial media
campaign to raise awareness of mental health
issues and the findings of the research,
including interviews on local radio and TV
and in the press.
A pilot training programme in mental health
was conducted for Imams (mosque prayer
leaders) and mosque leaders from across
the West Midlands.
Work is also underway to set up a mental
health clinic that will operate from the mosques,
staffed by volunteer Muslim doctors, consultants
and psychiatrists.
Training has been funded by the Birmingham
& Solihull Mental Health Foundation Trust to
enable a specialist Islamic counselling service
to be set up for the Muslim community,
staffed by trained volunteers and including
a telephone helpline.
Further proposals include working with service
providers to tackle the barriers to accessing
mental health services in order to improve
community engagement and help to fight
mental health stigma within the community.
21
section Project
Headingoutcomes
continued

3
Almost half (63) were aware that the community Figure 2:
engagement project with UCLan had taken How did the DRE community
place (13 were unsure) and 42 said they had engagement project help to bring
been involved in working with the project in about these improvements?
some capacity.
88.6%
Of 72 CDWs, 40% (29) had observed 100%
(31)
85.7%
(30)
improvements in mental health services for 80% 65.7% 68.6%
(24)
Black and minority ethnic communities as a 57.1% (23)
60% (20)
result of the NIMHE Community Engagement 37.1%
Project, 21% (15) were unsure if improvements 40% (13)

were connected to the project, and 39% (28) 8.6%

20%
said they had not observed any improvements (3)

connected to the project. 0%

Key improvements included improved awareness

and understanding, improved community contacts
and community engagement, better services and
information, improved communication and contact
with commissioners.
Highlighted community needs
Helped to open up access to communities for
service providers/commissioners
Helped identify new services that are needed

The improvements most frequently cited were
that the project highlighted Black and minority
ethnic communities’ mental health service
needs and raised the profile of mental health
issues in the communities (see figure 2).
Raised profile of mental health issues in
the communities
Created a team of trained community researchers to
continue work in the community for service improvement
Developed links between community groups and
service providers and commissioners

Obstacles in trying to achieve improvements Other

were reported by 57 CDWs in total. Those most
frequently mentioned were lack of financial
resources, and lack of support from healthcare
professionals.
Other obstacles mentioned less frequently
included:
• lack of local support or only tokenistic support
from commissioners, primary care trust service
providers and senior management
• racism/institutional racism/lack of interest in
Black and minority ethnic communities
• isolation of CDWs, coupled with lack of
Some CDWs provided more detailed comments:
‘The projects were very worthwhile. They
helped CDWs to look directly at community
concerns and pick up on the main issues.
However CDWs have been limited financially
in trying to meet the needs identified.’
‘While it was a brilliant idea, there was no
commitment by the NHS to take community
engagement forward. Another tick box
exercise.’

support and training and unreasonable
demands to show outcomes
• lack of strategic direction
• lack of power to really effect change.
‘Even though I have not observed any direct
improvement, the community engagement
project reports did give me inspiration and
tools for working towards improving mental
health services for BME communities in my
particular area.’

22
Recommendations from section
the community organisations

This section summarises the detailed
recommendations from the community
engagement studies of the next steps needed
to reach the DRE aims. These are presented
under the following headings:
• Fear of mental health services
• Effective therapies and interventions
4
4.2 Effective therapies
and interventions
•  Choice and combination of treatments
– including talking therapies, complementary
therapies, social interaction, and leisure,
educational and occupational activities.
• Community-based social interaction and

• Culturally appropriate treatment activities – opportunities for social

• The journey towards recovery, and interaction and participation in activities to
maximise the effectiveness of prescribed
• Active involvement of BME communities
treatment for those with mental health
and services users and carers.
problems and maintain the mental wellbeing
4.1 Fear of mental health services of other community members.
• Increased access to talking therapies
A range of measures aimed at working
gradually towards lessening fear were – these must be culturally, spiritually and
suggested. linguistically appropriate.
• Education – to increase awareness of
• Increased access to complementary
mental health conditions and reduce the therapies – available as standard treatments
stigma attached to them, in a variety of within mainstream mental health services.
media, in the relevant locally used languages
and in written, oral and visual formats.
• Terminology – a more acceptable term for

‘mental health’ services.

• More community-based services –

services that are offered in a particular

locality, and staffed and run by members
of a specific Black and minority ethnic
community.
• Service user roles – more opportunities

for service users to participate in planning

services, advocacy services and mental
health training for new and existing
professionals, and encouragement to set
up self-help and peer support groups.
• Support groups – more culturally

sensitive support groups on stigma and

the consequences of denial of mental
health problems.
• Partnerships – partnership working

between community organisations and

national mental health organisations,
such as the Alzheimer’s Society, to challenge
ignorance and stigma about mental health
problems within the community.

23
section Recommendations from
the community organisations

4
continued

4.3 Culturally appropriate treatment 4.3.2 Faith and religion

and interventions • Religious beliefs to be explored at diagnosis
4.3.1 Language and during treatment.
• Translated information – more translated • Training in the different faith and cultural

written information in relevant local traditions – to be a central component of

languages.
• Information in a variety of media – phone
lines, DVDs and workshops, and also radio
and television programmes and websites.
the training and continuing professional
development of all staff who work in mental
health services.
• Partnership work between mental health

• Bilingual workers.
• Better access to interpreters.
• Community workers who speak the local
community languages and can provide
information about mental health services
and signpost people with mental health
problems and their carers to them.
service providers and religious and community
organisations.
• Greater treatment choice.
• Appropriate inpatient facilities with
resources for religious practices,
including worship.
• Dissemination of good practice throughout

• Training for interpreters in mental health

mental health services.
and cultural issues. 4.3.3 Food
• English classes.
• Staff training on dietary needs.
• Review translating and interpreting
• The provision of halal and
services to identify unmet needs, audit their vegetarian food.
quality, and monitor service users’ language
• Black and minority ethnic chefs.
needs.
• Food-based activities as an element
• Increased funding for interpreting
of mental health services.
services.
• Other recommendations include:

–  train members of local communities as

translators and interpreters
–  do not use family members as interpreters.

24
 section

4.3.4 Gender 4.3.5 Ethnicity of mental

4
• Gender-specific services – centres for health service staff
women and men, outreach workers to target • Increase the numbers of Black and

housebound women, gender-specific spaces minority ethnic staff.

within mental health services. • Involvement of Black and minority ethnic

• Choice of same-gender workers. communities, including users of mental

• Improve women’s knowledge of mental health services, in staff training in cultural
health services. competency.
• Provision of childcare at mental health • Increase volunteering in mental health

services. services among Black and minority ethnic

• New posts to address the mental health
service needs of local Black and minority
ethnic women. Alimas and alims (female
and male Muslim scholars) to be employed
to work with mental health services.
• Education and involvement of
religious leaders and workers in
mental health issues.
• Training for mental health service
professionals on a variety of issues linked
with gender, including domestic violence and
the effect of the asylum-seeking process on
mental health.
populations.
• Organisational representation by Black
and minority people on relevant local NHS
and primary care trust forums, and panels
concerned with detention under the Mental
Health Act 1983.
• More Black and minority ethnic
advocates, ambassadors and champions.
4.4 The journey towards recovery
•  Action to address the social exclusion
of service users.
Faith and religion – stronger links between
•

• Community member and service user

mental health services and faith- and
religion-based organisations.
involvement in services.
• Increased community awareness and
• Further research on:
understanding of mental health.
–  the mental health needs of young Black
• Peer support – statutory services to link to
Caribbean males who are vulnerable
self-help groups, mentoring and befriending.
to suicide
–  women with mental health problems
who also experience domestic violence
and other abuse
–  the effect of mothers’ poor mental health
on their children and families
–  a longitudinal study of women’s
experiences in mental health services,
to demonstrate pathways to recovery.

25
section Recommendations from
the community organisations
4
continued
4.5 Active involvement of Black
and minority ethnic communities,
service users and carers
Many of the following recommendations echo
those above, and represent the overall message
that emerged from all the studies – the need for
greater involvement of Black and minority ethnic
communities and service users and carers in the
planning, organisation and delivery of mental
health services.
Detailed recommendations include:
•  training and proactive recruitment of Black
and minority ethnic people so that they are
represented at all staffing levels within mental
health services
• community-based services, staffed and run
by members of the target community
• service user input into planning services
• service user input into advocacy services
• increased input by Black and minority
ethnic community members (including
mental health service users) into cultural
competency training for all mental health
service staff, including all those who treat
service users and come into contact with
them (such as receptionists) and for chefs
and interpreters
26
•  support to Black and minority ethnic
community organisations and their
members (including mental health service
users) to provide information to members
of their communities about mental health
and mental health services, in order to address
the stigma of mental illness and encourage
help-seeking
• encouragement to set up self-help and
peer support groups for service users and
other community members who want to
maintain their mental wellbeing
• funding for community organisations to
provide opportunities for social interaction
and a range of leisure, educational and
occupational activities
• partnerships between mental health service
providers and religious and community
organisations to increase all parties’
knowledge and awareness of faith and
religious mental health service needs
• recruitment of Black and minority ethnic
chefs to work in mental health services that
provide food
• recruitment from the local community of
bilingual workers, interpreters, community
workers, outreach workers, ambassadors,
advocates and champions to act as
links between mental health services and
the community
• opportunities for service users to
volunteer at the services they attend, and
• services to encourage peer support to
service users via mentoring and befriending.
Delivering Race Equality
– some reflections
A number of individuals were invited to
contribute personal and professional
commentaries on aspects of DRE. This is
an excerpt from the reflections on DRE
and the way forward offered by Marcel Vige,
Manager of Diverse Minds at Mind.
The real dilemma for DRE has been the need
to negotiate the divergent beliefs, views,
even political priorities about the nature of
its subject matter – where does the catch-all
phrase BME begin and end? Is ethnic disparity
an aberration arising from inadequacies within
mental health or an inevitable function of
wider differentials? To what extent can the
ideal of cultural competency in therapeutic
approaches be achieved, whilst adhering to
clinical versions of ‘normality’, and the
perceived need for threat-management?
Whilst the very essence of what DRE is about
is in a state of flux, somehow the strategy has
had to progress with its change agenda – akin
to navigating a journey upon shifting sand.
1
Department of Health (2009). New Horizons: towards a shared vision for mental health. Consultation. London: Department of Health.
2
See www.dh.gov.uk/en/Managingyourorganisation/Commissioning/Policyguidanceandtoolkits/DH_100305
section
5
Despite this backdrop, DRE has been successful
in generating an array of local projects that
engage communities in novel ways. Also,
within some PCTs, DRE has underpinned a shift
in consciousness around responding to the
mental health needs of diverse communities.
A critical aspect of this was the willingness
of the PCT to take risks – supporting projects
to engage with communities in creative ways.
Though it’s hard to quantify such effects,
it’s fair to say that the extent to which DRE
has facilitated improvements in understanding
of and response to BME mental health issues
at the juncture between local strategy,
implementation and service provision is
indicative of its overall success.
Though unfortunate that such leadership fell
short in maintaining the consistency and
integrity throughout its implementation, DRE
has laid down a foundation both in terms of
community-based engagement projects and
increased capacity of local service developers
and providers to make provision culturally
competent. The task going forward will be to
incorporate such approaches into strategies
such as New Horizons1, World Class
Commissioning2, professional training
and development, indeed all initiatives and
strategies that have a bearing on BME
mental wellbeing. DRE was the first step.
The question now is “Where to from here?”
27
section references

16
1: Department of Health (2005)
Delivering race equality in mental health care:
an action plan for reform inside and outside
services and the Government’s response to
the independent inquiry into the death of
David Bennett. London: Department of Health.

2: Fountain J, Patel K, Buffin J (2007)

Community engagement: the Centre
for Ethnicity and Health model.
In: Domenig D, Fountain J, Schatz E,
Bröring G (eds). Overcoming barriers:
migration, marginalisation and access to
health and social services. Amsterdam:
Foundation Regenboog AMOC pp. 50-63.

3: Norfolk, Suffolk and Cambridgeshire

Strategic Health Authority (2003)
Independent inquiry into the death of David
Bennett. Cambridge: Norfolk, Suffolk and
Cambridgeshire Strategic Health.

28
 University of Central Lancashire
International School for Communities, Rights and Inclusion
School Office, Harrington 122
Preston, PR1 2HE
United Kingdom

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