By Kuldip Kaur Kang
We know that black, Asian and minority ethnic (BAME) people in England are disproportionately detained under the Mental Health Act 1983 (MHA), compared to the general population.
Once detained, it is unclear what impact systemic challenges are having on providing person-centred care to inpatients, and, specifically, how people of BAME backgrounds are supported to meet their religious and cultural needs when in hospital. As part of my master’s research during the Think Ahead programme, I set out, together with Dr Nicola Moran (University of York), to consider inpatient staff views on meeting the religious and cultural needs of people from BAME backgrounds who are detained under the MHA or receiving informal treatment on a mental health ward.
Religious and cultural needs integral to successful recovery
As a mental health social worker from a BAME background, the question of awareness often haunts me, particularly when I visit inpatient wards, environments traditionally dominated by the medical model. It also comes to mind when I see first-hand the barriers that people with a similar background to my own face when accessing mental health services.
Before undertaking my research, my suspicion was that services are not always inclusive of religious and cultural needs, and this sat uneasily with me. These needs may form a fundamental aspect of a person’s identity and how well they navigate their recovery, so it’s vital that they are properly understood. Research suggests that religious and cultural practices may serve as either a protective coping mechanism, or an additional risk, during times of mental distress. In the first instance, such beliefs may bring comfort to a person, while in the second, a person may, for example, believe that their symptoms are evidence of punishment by a higher power.
Our research took the form of nine semi-structured interviews, conducted with inpatient staff in the same NHS Trust – including a psychiatrist, an occupational therapist, nurses, managers, deputy managers and healthcare assistants. Six of the participants described themselves as White British and three were from BAME backgrounds (African and Indian). Participants were asked questions about their experiences and understanding of the religious and cultural needs of inpatients. This included whether assessment processes were in place to identify such needs and whether staff had received training in this area. We also asked respondents to identify any challenges they faced, and suggestions they had for improving on current practices.
Barriers to meeting religious and cultural needs
Staff felt meeting religious and cultural needs was an important aspect of recovery and relationship building, but that they lacked the resources, confidence and knowledge to do so – especially in the case of smaller and less well-known ethnic minorities. Most significantly, we found that staff could, and did, attribute the expression of these beliefs to a person’s mental illness, sometimes mistakenly treating them as delusions rather than genuinely held beliefs.
For example, one staff member described an occasion when an inpatient of Ghanaian background believed somebody was practising voodoo on him – a common cultural belief in Ghana – but staff interpreted this to be a delusion. This finding exemplifies wider issues within mental health services, including how gaps in knowledge create and maintain inequalities in how people of a BAME background access and receive services.
Our research also found that:
- There was no consistent tool used to record a BAME person’s religious and cultural needs and staff lacked the knowledge to explore such needs.
- Staff valued the involvement of BAME inpatients’ families but it could be detrimental at times, particularly if they encouraged the person not to comply with medication.
- The ward functioned according to routines and processes which were not flexible to needs of BAME persons – for example, failing to enable them to fast for Ramadan.
- Staff found it difficult to clarify whether the expression of religious beliefs was due to the symptoms of a person’s mental illness. The role they play as a coping mechanism was also less recognised.
- Not all staff received training on meeting religious and cultural needs of BAME inpatients, although they were driven by providing person-centred care where resources and processes were readily available. They also utilised the internet, and sought guidance from BAME colleagues and chaplaincy, to inform themselves on these issues.
There are a range of conclusions and potential solutions that staff and services can draw from this research. For example, we found an appetite among inpatient staff for:
- A directory of religious and cultural needs;
- An assessment tool to identify these needs and enable staff to meet them.
If provided, such solutions would be readily accessible and available when needed, in environments which are often pressurised and where time is limited.
Meeting these needs directly relates to core social work values of anti-oppressive and anti-discriminatory practice, and has a legislative basis under the Equality Act 2010. This research was, coincidentally, published at a time when the Black Lives Matter movement had gained momentum, highlighting deep-rooted inequalities across different sectors and policy areas.
However, what is not a coincidence is that these needs are not being met consistently in inpatient settings, and the same may be true of services on the whole. The national workforce stocktake of mental health social workers in NHS trusts highlighted that BAME social workers are less represented in NHS mental health trusts than the wider social work workforce. This did not form part of the research, but, in my view, it would be interesting to consider whether this is linked to a wider need for mental health social work to reflect upon how we promote, advocate and put into practice our commitment to social work values.
It should also be made clear that staff in inpatient settings should not be held entirely responsible for our findings. Mental health recovery is based upon a biopsychosocial model. There is opportunity for social workers, whether employed by the local authority or NHS, to work with our colleagues on wards to ensure the social model is part of supporting inpatients in meeting their religious and cultural needs. This could be through something as simple as a discussion of religious and cultural needs being built into a ward round, or community staff sharing information with inpatient staff about the religious and cultural beliefs and practices of the service users they work with. This way we can reinforce our identity as mental health social workers in an arena of mental health dominated by the medical model, by championing religious and cultural needs using the social model.