This Black History Month, placement students Aliyah (EDIT Lab) and Tin Tin (BioResource) highlight the complex racial disparities which exist within mental health treatment and care, and discuss a range of changes that can be made, on an individual and structural level, to address this systemically in the workplace.
Tin Tin, BioResource placement student
Aliyah, EDIT Lab placement student
In the UK, there are racial disparities in mental healthcare. Black individuals are over four-times more likely than their White counterparts to be detained under the Mental Health Act (1). Furthermore, national data indicates that Black/Black-British adults are less likely to receive treatment for depression compared with White adults (2). Both of these disparities may be due to differing levels of access to care and treatment among other factors. Discrepancies are also seen in other areas of the world, notably the Black-White depression paradox (3) in the U.S., one which explores the lower prevalence of major depressive disorder in Black/Hispanic individuals as compared with White individuals, despite their generally being exposed to more life stressors (relative to their counterparts).
“Efforts to address the burden of mental health among
Black populations will also require attention to issues of treatment availability and institutionalised racism in the healthcare system that undermine access to care.” – (Pamplin et al., 2021, (3))
This quote sums up the complex interplay between systemic racism and [poorer] access to adequate mental healthcare for Black and racialised minority groups. Even after receiving treatment, the health outcomes of individuals from Black and other racialised minority groups are less positive than those of their White counterparts (4). Historically, there hasn’t been much racial diversity in research samples (5) which may have influenced the cultural sensitivity of currently developed treatments. Clinical practitioners are shown to also comprise mostly White populations. For example, as of 2019, only ~9% of qualified clinical psychologists in England and Wales identified as belonging to minority ethnic groups, despite comprising 13% of the population (6). It is clear that we have much more to learn about the best ways to diagnose and treat diverse populations.
To target these biases, strategies relating to cultural competency are necessary implementations in clinical settings. Defined as “being aware of your own cultural belief
s and values and how these may be different from other cultures” as well as “being able to learn about and honour the different cultures of those you work with” (7), developing a sensitive understanding of diverse beliefs can enable healthcare professionals to better respond to their patients’ needs.
What changes can be made as an individual?
While there are some strategies for individual level change, the evidence to support them is lacking. An intervention rooted in socio-cognitive psychology (8) suggests exploring individual-based change by offsetting your own biases through a six-step process of individuation. This process ranges from better understanding psychological processes (namely bias) to improving one’s ability to build partnerships with patients dissimilar to them by increasing perspective-taking and affective empathy. Research may benefit from exploring the efficacy of these strategies which incorporate active listening.
Cultural Competence Training
Changes can also be made at an institutional level through training and education programmes. For example, Cultural Competency Training (CCT), launched in 2003, is an online NHS course for clinicians to undertake as optional training (9). However, there is a lack of research into whether CCT actually improves health outcomes in Black patients, despite the training being launched two decades ago. Furthermore, research suggests that clinicians can overestimate how culturally competent the care they provide is, especially if they have undertaken CCT and treated a greater proportion of non-White patients. This is a big problem, as these factors are not reliable indicators of how culturally sensitive the care provided actually is. Critically, patients often perceive interactions in healthcare settings as far less culturally competent than their clinicians, indicating a need for tools that adequately assess cultural competency through the lens of the patients receiving care (10).
Putting Black m
ental health first
In response to a lack of care that meaningfully serves the cultural needs of Black individuals, anti-racism grassroots organisation Black Thrive Lambeth (BTL) launched Culturally Appropriate Peer Support Advocacy (CAPSA) in 2021. CAPSA aims to address the inequality that Black people face in the healthcare system, particularly by improving their access to mental health services. Peer Support Workers are trained to provide individual support to service users in both community and inpatient settings, while CAPSA advocates supporting individuals throughout the process of accessing mental health services and making informed decisions regarding their care.
As an organisation that is planned by and with local members of the Lambeth Black community, BTL shares a common identity with the community they serve. Their CAPSA initiative views clinical knowledge and lived experience as equally valuable, and prioritises fostering trust between Black individuals and the healthcare system. Although there is not yet much research on the benefits of CAPSA on Black health outcomes, community-focused initiatives such as this may be key to driving positive changes for Black individuals’ relationship with the healthcare system that NHS-provided CCT fails to adequately address.
“…To be referred to community and voluntary services for my community, who will understand the battles in society we have to face based on the colour of my skin.”
– Quote taken from CAPSA, Black Thrive
In sum, cultural competency in the UK healthcare system still has a long way to go. Researchers have tried to find ways to tackle the reasons behind differing rates of mental illness in different populations, but we all have our part to play both individually and in the workplace. In clinical practice, the effectiveness of NHS-provided cultural competency training is still under-researched. Practitioners and patients also disagree on how culturally sensitive their interactions are. Local, community-based strategies to prioritise Black individuals’ access to, and experience with healthcare may guide future policy when addressing cultural competency and racial disparities in the healthcare system.
Read more here (references):
- NHS. (2021, October 26). Mental Health Act Statistics, Annual Figures – 2020-21. NHS Digital. https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-act-statistics-annual-figures/2020-21-annual-figures
- McManus, S., Bebbington, P., Jenkins, R., & Traolach Brugha. (2016). Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds, UK: NHS Digital. https://openaccess.city.ac.uk/id/eprint/23646/1/mental_health_and_wellbeing_in_england_full_report.pdf
- Pamplin, J. R., & Bates, L. M. (2021). Evaluating hypothesized explanations for the Black-White depression paradox: A critical review of the extant evidence. Social Science & Medicine, 281, 114085. https://doi.org/10.1016/j.socscimed.2021.114085
- Skelton, M., Carr, E., Buckman, J. E. J., Davies, M. R., Goldsmith, K. A., Hirsch, C. R., Peel, A. J., Rayner, C., Rimes, K. A., Saunders, R., Wingrove, J., Breen, G., & Eley, T. C. (2022). Trajectories of depression and anxiety symptom severity during psychological therapy for common mental health problems. Psychological Medicine, 53(13). https://doi.org/10.1017/s0033291722003403
- Henrich, J., Heine, S. J., & Norenzayan, A. (2010). The weirdest people in the world? Behavioral and Brain Sciences, 33(2-3), 61–83. https://doi.org/10.1017/s0140525x0999152x
- BPS. (2019, December). BAME representation and psychology – The British Psychological Society. Www.bps.org.uk. https://www.bps.org.uk/psychologist/bame-representation-and-psychology
- National Technical Assistance and Evaluation Center for Systems of Care. (2009). Defining Cultural Competency – Child Welfare Information Gateway. www.childwelfare.gov. https://www.childwelfare.gov/pubs/acloserlook/culturalcompetency/culturalcompetency2/#:~:text=%22%20Cultural%20%20competency%20%20means%20being%20%20aware
- Burgess, D., van Ryn, M., Dovidio, J., & Saha, S. (2007). Reducing racial bias among health care providers: Lessons from social-cognitive psychology. Journal of General Internal Medicine, 22(6), 882–887. https://doi.org/10.1007/s11606-007-0160-1
- NATIONAL HEALTH SERVICE. National Institute for Mental Health in England. (2003). Inside outside: improving mental health services for black and minority ethnic communities in England – Social Care Online. www.scie-Socialcareonline.org.uk. Social Care Institute for Exellence . https://www.scie-socialcareonline.org.uk/inside-outside-improving-mental-health-services-for-black-and-minority-ethnic-communities-in-england/r/a11G00000017rChIAI
- Rathod, S., Graves, E., Kingdon, D., Thorne, K., Naeem, F., & Phiri, P. (2020). Cultural Adaptations in Clinical InteractiONs (CoACtION): A multi-site comparative study to assess what cultural adaptations are made by clinicians in different settings. International Review of Psychiatry, 33(1-2), 1–13. https://doi.org/10.1080/09540261.2020.1750818
