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African-Caribbean people in the UK are twice as likely as white people to be diagnosed with a mental health problem but are less likely to access treatment and care. These bald facts raise significant concerns. Are mainstream mental health organisations failing to provide adequate care? Can black mental health organisations fill the gap?

The Black Spaces project, funded by the Mental Health Foundation (MHF), set out to discover how seven mental health agencies for ethnic minorities try to provide a specialised service. The project aimed to disseminate lessons learned to other black and mainstream mental health services.¹

Andrew McCulloch, chief executive of the MHF, says: "I have personally observed many problems, including patronising and paternalistic attitudes, over-representation in some parts of the system and under-representation in others, poor involvement of families, carers and communities, and possible covert racism."

The agencies are based in Manchester, Wales, London and the Midlands, including the African Caribbean Community Initiative in Wolverhampton, which operates a day centre offering computer classes, sports facilities and support groups. Another is the Zindaagi project. It aims to develop and co-ordinate support services for young Asian women who are vulnerable to suicide and self-harm. In West London, the Forward Project aims to keep people of African and African Caribbean descent out of psychiatric hospital whenever possible.

Similar information was collated about each agency, for example: location and suitability of the building, target population, services on offer, number of staff and volunteers, number of students involved, funding and a brief history of the organisation. The report's findings showed the importance of:

• Working in partnership with key organisations.
• Advocacy to secure black people's rights.
• Empowering users.
• Cultural sensitivity to black service users.
• Not dancing to funders' tunes.
• Involvement of families and the community in care.

The importance of partnership working is illustrated by some of the organisations that have established valuable relationships with housing associations, psychiatric units and benefits offices. For example, African Caribbean Community Initiative in Wolverhampton works with the local psychiatric hospital, negotiating care and discharge packages as well as with the benefits office.

Advocacy work on behalf of clients in hospital settings has proved vital, especially concerning diagnosis and treatment of black people. Preventive work is also important to try to stop unnecessary admissions to hospital. Black organisations have also helped to ensure that people's rights under the Mental Health Act 1983 are respected in hospital settings. For example, Awaaz, a service for Asian people in Manchester, employs advocacy workers to negotiate with health professionals on diagnosis and treatment for people from the Asian community and ensure that interpreters are appropriately versed in mental health issues to represent their clients' wishes.

The labelling of the black agency itself can be important in terms of accessibility, safety and cultural sensitivity. For example, Awaaz chose not to have a name that identifies it with mental illness because this carries a negative meaning for many within Asian communities. It is also trying to provide a wider range of services so it is not solely associated with mental illness.

Agencies that are directly aware of the impact of racism and the issues surrounding mental health within some cultural settings are invaluable. The researchers recognised the importance of black organisations employing black staff who understand the social and political experiences of black people's lives in the UK.

It was felt that some projects were in danger of losing their focus on mental health or black issues in the search for funding because there have been problems attracting core funding. However, some organisations found this has some advantage, in that they are not dictated to in terms of service delivery.

Based on these findings, researchers including service users (see panel, top right) compiled a set of suggestions for improving mental health service provision. This starts with training professionals, including GPs, nurses and social workers. Students training for mental health work should be encouraged to take placements within the black voluntary sector. This should be a part of continuous professional development.

In terms of quality standards, the researchers suggest self-assessment of the cultural and linguistic competences of staff and annual reports on an organisation's progress in relation to ethnic issues. There should also be mechanisms to allow consumer and community feedback to establish user-satisfaction with services.

Mental health organisations should respect cultural differences. At Awaaz, for example, there are targeted gender services, which show an understanding and respect of Asian culture, where men and women, particularly if unmarried, often work or socialise separately. Having staff who speak and understand local languages is very important, especially if people are in mental distress. Activities should be planned with an understanding of people's religion, allowing time and space for prayer. A culturally appropriate diet is also important for some black and Asian people.

Service users should be encouraged to realise their potential, with more focus on where people were before they had a psychological problem. More attention should be paid to retraining people and getting them into employment. For example, attending adult education classes helps with integration in the local community.

The researchers also emphasised the importance of infrastructure support for black voluntary sector organisations as they expand. Different projects should be encouraged to link up so they can develop new ideas and different ways of working.

A team of African-Caribbean, Asian and African service user consultants should be developed to help with organisational development within the black voluntary sector.

The 1999 National Service Framework for Mental Health emphasised the poor sensitivity of existing services to African and Caribbean people. And one of the key aims of the 2002 NHS Plan was to address inequalities in health, especially for people from minority ethnic communities. Yet the Department of Health issued a report in March this year, Inside/Outside, acknowledging that neither of these policy initiatives adequately address the particular needs of black people.²

However, McCulloch says: "I believe there is real hope of providing better mental health services to black people through a combination of more sensitive mainstream services and support for black-led services, working in partnership with the statutory sector."

About black spaces

The project forms part of the MHF's focus on user-led research. It is part of the Strategies for Living programme that encapsulates a belief in learning from the experience of users as well as staff. A small steering group of experts guided the project and a team of consultants, including mental health service users, visited the organisations. The lead consultant spent at least three days with each agency, shadowing their work and acting as an observer and student. A separate two-day visit was also organised for user consultants to provide feedback.

Nicola Hill is editor of the Black Spaces project report.

References

¹ Mental Health Foundation, Black Spaces report, MHF 2003, www.mentalhealth.org.uk/html/content/black_spaces.pdf

² Department of Health, Inside/Outside: Improving Mental Health Services for Black and Minority Ethnic Communities in England, 2003