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Chapter Six Ethnicity and Mental Health

Introduction

'The extent of social exclusion among [black and minority ethnic] communities, the levels of racism and racial discrimination experienced by them in public life and, more pertinently, when they come into contact with institutional agencies are key determinants of psychiatric morbidity within black and minority ethnic groups.' (Sashidharan, 2003, p.11)

Understanding the implications of ethnicity means acknowledging first, the impact on mental health and well-being of people from black and minority ethnic communities of discrimination and victimisation and, secondly, the potential or actual institutional racism of services and systems, including mental health service systems.

What is also important to understand is the heterogeneity of those encompassed within the category 'black and minority ethnic communities'. The census analysis for Scotland includes as 'minority ethnic population': Indian, Pakistani, Bangladeshi, Chinese, other South Asian, Caribbean, African, Black Scottish or any other Black Background, Any Mixed Background and Any Other Background. In addition, are those who experience discrimination and disadvantage not just on the basis of ethnicity, but because of their status as refugees or asylum seekers, or who are gypsies or travellers. Another distinction is between identities based on 'visible' characteristics such as skin colour or 'invisible' dimensions such as religion or nationality, white Irish or European migrants, for example.

Within in each group there will be further divisions based, for example, on whether individuals were born in the UK or Scotland, or experienced migration; between the experiences of women and men within different groups; between the experiences of older people and younger people.

In addition to the social justice imperative of eliminating discrimination and racism, the likely increase in inward migration as a result of employment policies such as Fresh Talent, together with the legal responsibilities placed on public authorities by the Race Relations (Amendment) Act 2000 (see Chapter 2) together reinforce the necessity to identify and address the mental health inequalities stemming from lived experience and service responses.

Ethnicity and Mental Health: Some Indicators

Population profiles

• On the basis of the 2001 census, the minority ethnic population comprised just over 100,000 or 2% of the Scottish population.
• Pakistanis, were the largest minority ethnic group followed by Chinese, Indians and those of mixed ethnic backgrounds.
• Men comprise over one-half of the populations from African, Bangladeshi and Indian communities.
• For both males and females ethnic minority groups have a younger age distribution than white groups - with the exception of the Caribbean group more than 20% of the population is under 16 years of age.
• White Irish comprise just under 1% of the Scottish population.
• There are an estimated 10,000 refugees and asylum seekers in Scotland (Scottish Refugee Council figures, quoted on MEWS website accessed 23 June 2004), the majority living in Glasgow. These include around 70 different nationalities.
• The Scottish Executive twice-yearly count of gypsies/travellers estimates that there are around 1400-1900 gypsies/travellers on sites/in encampments in winter and 2000-2500 in summer. These figures do not include people permanently settled in housing ( MEWS website accessed 23 June 2004).

Indicators of prevalence

Information on the pattern of mental health problems among minority ethnic groups is complex and contested. As in relation to gender these are bound up with conceptual issues. In the context of ethnicity these relate to the universality and applicability of western psychiatric concepts and associated assessment/measuring tools. Sample populations on which estimates of prevalence are based i.e. community/population samples or hospital based will also generate different patterns. The latter reflects not just different levels of need, but different (and potentially discriminatory) pathways to care.

Apart from a study undertaken in the late 1980s of psychological distress among South Asians living in Glasgow (cited in Shah, 2004), no Scotland-specific studies appear to have been undertaken to indicate the prevalence of mental health problems among people from black and minority ethnic communities in Scotland.

'National' population based studies (for example, Nazroo, 1997; Singleton et al, 2001) reveal differences within and between different groups, but the findings can be inconsistent between studies: underlining the difficulties of being sure that the identified differences are valid, reliable or, in small samples, statistically significant (Nazroo, 1997).

A consistent finding (based on British data) is the higher rate of psychotic disorders among the African-Caribbean samples. The degree of difference is not the same between studies. Nazroo (1997), for example, points out that in his population based study the difference is not as great as in studies based on hospital admission rates. Further, Nazroo found that the differences within his sample were largely accounted for by the higher rates among African-Caribbean women compared with white women.

From a review of seven population based studies of 'common mental disorders' (anxiety and depression) Shah (2004) concludes that that the prevalence of these disorders among minority ethnic groups is equivalent to, or may be higher than among the general population.

Nazroo (1997) found that African-Caribbean people had a 60% higher rate of depression than white people; and the rate for African-Caribbean men was twice that of white men.

The design of instruments for measuring prevalence, different patterns of interpreting and presenting symptoms, different patterns of help-seeking behaviour, and mis- or underestimates of diagnosis are felt to account for the apparently lower levels of mental health problems among South Asian and Chinese populations. Nazroo (1997), for example, refers to the difficulties of translating the term 'depression' into South Asian languages.

Studies have, however, indicated high levels of un-reported psychological distress among Asian communities in general, and among Asian women in particular (Wilson, 2001). The rate of attempted suicide among young South Asian women is particularly high. Figures quoted in a recent Mentality report suggest that women born in India and East Africa have a 40% higher suicide rate than women born in England and Wales, and is particularly high in the age group 15-24 years (Tidyman, 2004; Gilbert et al, 2004). Rates of self-harm and eating disorders are also believed to be higher among adolescent South-Asian girls.

Research on mental health needs of asylum seekers/refugees suggests that many asylum seekers are likely to arrive with mental health needs as a result of their experiences (King's Fund, 2000, in Ferguson and Barclay, 2002). Work undertaken in Edinburgh in 2000 argues that it is the refugees and asylum seekers who are the most likely among Lothian's black and minority ethnic communities to experience mental health problems as a result of their life experiences (Munday and Oswald, 2000).

Although the discrimination experienced by Gypsy/Travellers has been documented,
the anxiety and distress experienced by women in particular noted, and the difficulties people have in accessing services acknowledged, it was not possible to find studies in Scotland of the prevalence of mental health problems among this group of people.

Other groups are also known to have specific mental health needs. With the caveat that it was based on a small (and heterogeneous) sample, Nazroo (1997) found the highest rates of mental illness among the white minority group (people who said they had Irish family origins or were white but had family origins outside Britain).

Service usage

Scotland-specific information is not routinely/centrally collected to indicate usage of psychiatric services, diagnosis, patterns of compulsory detention, treatments/ interventions and outcomes for people from black and minority ethnic communities. Where available, measures of service use by people from black and minority ethnic communities are ambiguous as indicators of need or accessibility. As noted above, over-representation and under-representation at different stages may both reflect in different ways discriminatory practices. However, without data it is not even possible to know what the questions are let alone to begin to identify possible explanations.

Where available the data suggest differential patterns of usage. For example:

• Data from a (British) population-wide sample suggests that compared with other groups, people from African Caribbean communities with mental health problems were just as likely as other ethnic groups to consult their GP, but were less likely to receive medication or other forms of treatment (Nazroo, 1997). Shah (2004) in his review of seven studies, found that people from minority ethnic groups with common mental disorders tend to have lower rates of treatment and received fewer anti-depressants and minor tranquillisers. The Caribbean and African group also appeared to use therapists, social workers and 'alternative' healers less frequently than white and south Asian groups.
• Analysis of the 2001 census by the Commission for Racial Equality ( CRE) revealed that, at the time of the census:

Forty-five people from a black or minority ethnic community were detained under the Mental Health (Scotland) Act 1984

1.2% of psychiatric patients were from ethnic minority communities, of whom:

33% were African

13% Pakistani

13% Indian

4% Chinese

4% Caribbean.

Given that African's comprise just over 5% of the minority ethnic population in Scotland this suggests that they may be disproportionately represented among the hospital population.

• Focusing specifically on high secure care, a review of admissions and discharges to the State Hospital over the period 1991-1998 revealed that of the 463 admissions over this period 2.0% were non-white (and all were male). Of the total of admissions 0.3% were Black-African, 1.0% Black-Caribbean, 0.3% Chinese and 0.3% Pakistani (Thomson et al, 2000). The 2001 census figures indicate that people who defined themselves as Caribbean and African comprised 0.04% and 0.10% of the Scottish population respectively. Although based on a slightly different time period the data may again tentatively suggest an over-representation of people from Black-African and Black-Caribbean backgrounds.
• Although not Scotland-specific, data from studies in England and Wales indicate that people of Irish origin are over-represented among users of psychiatric services (Bracken et al, 1998).

Ethnicity and Mental Health: Risk Factors

Risk factors

From a review of seven studies Shah identifies 17 risk factors for common mental disorders in ethnic minority groups (Shah, 2004). As Shah points out, many of these factors are the same as for the general population, including unemployment, absence of a full-time worker in the family, low standard of living and social isolation. Others are more specific to people from black and ethnic minority communities including victimisation, racial discrimination and discrimination in housing and employment. Although not referred to by Shah there are, additionally, within-group risk factors based on, for example, gender, age or sexual orientation.

Socio-economic disadvantage

Although, as Shah points out, some of the risk factors, particular those related to socio-economic disadvantage are the same as for the general population, data on the position of people from black and minority ethnic communities indicate that greater proportions are at risk of poverty and social exclusion. The significance of this is highlighted by Nazroo (1997) who found that, with the possible exception of people from Pakistan/Bangladesh, social class was inversely related to mental health outcomes: and households with no full-time worker had particularly poor mental health.

Some sense of the implications for people in Scotland can be obtained from an analysis of data from the 2001 census by the CRE that reveals that people from black and minority ethnic communities experience:

• Higher rates of unemployment than the white population.
• Lower levels of economic activity with a much greater reliance on one wage earner.
• Higher levels of self-employment and segregated employment.

There are differences within and between communities, both along these variables and in relation to variables such as education where there is evidence for both higher and lower attainment levels. Nonetheless even educational attainment is not an indicator of advantage: African communities have the highest levels of academic attainment and also the highest unemployment rate.

A study of the mental health needs of asylum seekers in Glasgow highlighted the impact of the voucher system. On the one hand the vouchers were seen as responsible for the poverty experienced by asylum seekers, and on the other, were felt to be a source of shame, humiliation and stigma (Ferguson and Barclay, 2002).

In terms of housing, the census data indicate that people from black and minority ethnic communities:

• Have a higher reliance on private rented accommodation.
• Higher levels of overcrowding.
• Have fewer household amenities such as central heating.

A recent study of homelessness among black and minority ethnic communities found that the incidence of recorded homelessness among these groups is significantly higher than across the population as a whole (Netto et al, 2004). The over-representation of people from these groups in overcrowded conditions or in Below Tolerable Standard housing, also suggests high levels of hidden homelessness. The report also notes that refugees, gypsies/travellers and women from black and minority ethnic communities escaping domestic abuse are particularly vulnerable to homelessness.

Racism, discrimination, victimization and violence

There is a large body of evidence that indicates the pervasive nature of racism, racist victimization and discrimination for people from black and minority ethnic communities. In addition studies indicate the impact of these experiences on mental health and well being (for example, Chakraborty and McKenzie, 2002; Janseen et al, 2003), though the precise nature of the relationship has been the subject of debate (see for example, Freeman, 2002). These experiences have two dimensions: the experience of racism in everyday life; and the potential racism experienced through contact with services including mental health services.

• According to one study undertaken in four British cities, including Glasgow, 'the experience of racism had become part of the everyday experience of black and minority ethnic people contacted. Being made to feel different in a variety of social situations and locations was largely seen as routine, and in some instances expected. Racist abuse was the most common form of everyday racism' (Chahal and Julienne, 1999).
• Recent Scottish data collected as part of a study of the policing of racist incidents in Strathclyde found that in the previous 12 months over three-fifths of visible minority individuals and over one-half of minority white participants (for example from Eastern Europe, England or Ireland) had experienced property damage, physical assault or offensive remarks or threats in a public place compared with around two-fifths of white Scots participants. The worst affected were women in non-white categories,
  of whom four-fifths had experienced offensive remarks or threats (University of Glasgow, c2004).
• The 2000 Scottish Crime Survey found that ethnic minority respondents had a higher risk of household victimisation; and 25% of incidents were considered by the victims to have been racially motivated. Ethnic minority victims were more likely than whites to be affected emotionally, anger being the most commonly cited emotion. Respondents from ethnic minority communities were five times more likely than white respondents to be concerned about racial attacks (Clark and Leven, 2002).
• In a 1999 survey of Gypsy/Travellers 62% of respondents interviewed reported experiencing prejudice or harassment during the previous year ( MEWS accessed
  23 June 2004).
• Data cited on the UK Disability Forum - Women's Committee website ( www.edfwomen.org.uk , accessed 10 May 2004) states that refugee women in the UK are suffering widespread mental distress because of fear of attack. One in two feel so depressed and anxious that they are unable to sleep at night, and many lock themselves indoors throughout the daytime in a self-imposed curfew.
• A study of asylum seekers in Glasgow found that verbal and physical racist harassment was an almost daily occurrence for asylum seekers and their children (Ferguson and Barclay, 2002). They saw this experience as seen as having a negative impact on their mental health.

According to a recent Mentality report 'Racism contributes to mental distress and leads to feelings of isolation, fear, intimidation, low self-esteem and anger, and an increase in negative life events which are considered unfair and lead to stress' (Tidyman, 2004).
As a result individuals can be left feeling powerless. Chahal and Julienne (1999) describe as 'profound' the effects of racist victimisation on the health and well being of the people in their study: respondents referred to feelings of anger, stress, depression and sleepless nights.

Studies involving people with mental health problems from black and minority ethnic communities illustrate not only the day to day experiences of racism but also how this is seen as contributing to their mental distress (Wilson and Francis, 1997; Essien, 2003).

Studies undertaken in England suggest that this experience of racism extends to health services, including mental health services.

In addition to the high profile cases, such as the David Bennett inquiry (Norfolk, Suffolk and Cambridgeshire Strategic Health Authority, 2003) a number of studies suggest the barriers people from black and ethnic minorities face to obtaining appropriate, responsive and effective mental health services. One study, for example, describes the 'circles of fear', that stop black people from engaging with mainstream mental health services which are experienced as inhumane, unhelpful and inappropriate (Sainsbury Centre, 2002). Another study of African and African-Caribbean mental health service users in England found that a number of the sample felt misunderstood within the mental health system because they are feared, stereotyped or ignored (Wilson and Francis, 1997).

Although a number of small scale, local studies have been undertaken (Netto, et al, 2001) the experiences of people from black and minority ethnic communities in contact with mental health services in Scotland does not appear to have been researched in-depth.

Stigma

The stigma and discrimination experienced by white people with mental health problems are replicated for people from black and minority ethnic communities. A recent Mentality report (Tidyman, 2004) suggests that the stigma and taboo associated with mental illness can lead to discrimination and harassment from with these communities. Some of the black women interviewed by Essien (2003) felt that having a psychiatric diagnosis was a sign of losing their self-respect in their communities A Mind factsheet on the mental heath of Chinese and Vietnamese people in Britain ( www.mind.org.uk , accessed 18 July 2004) for example, draws attention to the stigma that can attach to mental health problems within these communities. As a result people may be reluctant to seek help. Similarly, a study by Gilbert et al (2004) describes how the concept of izzat - the shame and dishonour that can be brought to others by one's own behaviour - may deter South Asian women from using mental health services.

Potentially at least, people with mental health problems from black and minority communities are at risk of experiencing double or triple jeopardy: discrimination based on ethnicity; and stigmatisation on the part of the majority and minority communities based on having a mental illness.

Life events/experiences

• Studies in England suggest that there are higher levels of contact with criminal justice systems among people from African Caribbean communities (Mallet, 2004); higher admissions to psychiatric hospitals via the courts; and greater involvement of the police in hospital admission (Sainsbury Centre, 2002).
• For asylum seekers and refugees there is both the impact of the past and the experience of the present to cope with. As summarised by Munday and Oswald (2000) 'the trauma of having to leave one's homeland, the insecurity of one's status in the UK, the constant worrying about relatives and friends left behind, survivors guilt, Post Traumatic Stress Disorder, the experience of war, rape or torture are well documented triggers for the development of mental health problems'. In addition, Ferguson and Barclay (2002) describe the impact of the voucher system and dispersal policies on asylum seekers in Glasgow, and the daily experience of racial harassment. Some people saw the pressures of living as an asylum seeker in Glasgow, rather than their experiences in their own country as affecting their mental health.
• For Gypsy/Travellers the life experiences may include 'feeling trapped in a site where no-one would want to live' (Scottish Executive, 2001b) or of being forcibly moved on (Save the Children, 2000).
• Social isolation and limited social networks are known to impact on mental health and well-being (see Chapter 4). For people from black and minority ethnic communities, differences in language, employment patterns, fear of actual or potential racist abuse or violence and lack of appropriate social supports may contribute to social isolation. For the asylum seekers interviewed by Ferguson and Barclay (2002), for example, isolation from the host community was compounded by isolation from their own community. Women with young children were particularly isolated.

Multiple identities: Multiple disadvantage

• The different experiences of men and women across the total population (see Chapter 5) are replicated within different black and ethnic minorities groups. In terms of socio-economic conditions and social exclusion, role expectations, expression or presentation of distress, access, use and responsiveness of services, studies suggest different patterns for men and for women within and across black and minority ethnic communities (Nazroo, 1997; Fatunmbi and Lee; 1999; Bhardwaj 2001; Wilson, 2001; Essien, 2003; Mirza and Sheridan (2003); Zappone, 2003; Gilbert et al, 2004). Several studies for example, describe how, as people from black and minority ethnic communities women experienced not just 'racialisation of health' in the sense that others' perceptions of their health needs were informed by racial presumptions, but gendered racialisation.
• Age too may impact on both risk factors and outcomes. In addition to socio-economic factors that may impact on different age groups, within-group expectations, and the attitudes of the majority culture may both affect mental health and well being in different ways and with different outcomes.

Ethnicity and Mental Health: Resilience Factors

Netto et al (2001) identified two studies illustrating how women from black and minority ethnic communities, rather than presenting themselves as passive victims of a discriminatory or racist society, undertook a number of strategies to prevent deterioration of their own psychological health.

Several other studies describe the strategies women in particular from black and minority ethnic communities draw upon. These include;

• Developing social networks, resources and support: drawing on their cultural capital to find solutions or develop strategies based on their transnational networks (Zappone, 2003); establishing self-help groups (Wilson, 2001; Essien, 2003).
• 'Cultural strategies: constructing identities as survivors and 'challengers for injustice' in opposition to others' negative constructions (Zappone, 2003).
• Developing 'self-healing strategies' or coping mechanisms (Essien, 2003).
• Obtaining support and comfort from spiritual beliefs and practices (Wilson, 2001).

Ethnicity and Mental Health: Preventing and Responding to Risk

Mental health improvement and promotion

The Cares of Life project, in Southwark, South London aims to build community capacity to assist early intervention and build partnerships between the black community and statutory and non-statutory agencies (Olajide, 2004). No other studies, were identified in the course of the review looking specifically at the experience of people from black and minority ethnic communities of programmes aimed at improving/promoting mental health and well-being.

In Scotland the National Programme for Improving Mental Health and Well Being has funded a development post within the National Resource Centre for Ethnic Minority Health ( NRCEMH), to develop capacity within Scotland. Activities to date include a Scotland-wide assessment exercise of mental health and well-being policy and practice as it relates to people from black and minority ethnic communities. A series of seminars has also been held across Scotland exploring different models for responding to the mental health needs of people from black and minority ethnic communities. The National Programme is also supporting the development of a transcultural mental health network.

Responding to mental health problems

A common theme across much of the documentation consulted was of the barriers to access appropriate and timely services. Barriers include:

• Language.
• Stereotyping.
• Lack of awareness of different understandings of mental illness.
• Cultural insensitivity including toward religious or cultural beliefs.
• 'Colour-blind' approach.
• Direct or indirect racism - individual and institutional.

These barriers are experienced at each stage from primary to secondary and tertiary care. People may, for example, have difficulty accessing appropriate primary prevention services such as counselling. One Scottish study of counselling services among Asian people, for example, found that most mainstream services provided counselling only in English, in the context of a limited number of black-led organisations (Netto et al, 2001). People may be reluctant to access services because of lack of confidence or trust. As a result they may only come to the attention of services in a crisis. On the other hand, patients from black and minority ethnic communities may be less likely to have their mental health problems recognised by a GP or may be mis-diagnosed (Tidyman, 2004; Bhui, 1997, in Wilson, 2001). They may not be offered the same range of treatment options (Nazroo, 1997; Shah, 2004), or be referred early enough for specialist mental health services (Netto et al, 2001; Sainsbury Centre, 2002). Advocacy services may also be underdeveloped. One study found that where mainstream advocacy existed for mental health users they were inaccessible and often inappropriate to the specific needs of black service users and carers (Joseph Rowntree Foundation, 2002).

Work undertaken preparatory to the development of guidance on the treatment of black and minority ethnic community detained patients (Patel et al, 2003) reveals the
pre-admission and after-care issues that affected care. These included:

• Stigma towards mental health in some communities.
• Language difficulties.
• Unfamiliarity among people from black and minority ethnic communities of mental health services and systems.
• Different concepts of mental health.
• Concerns about the ability of services to meet expectations of safety, privacy and dignity.
• The quality of referral information, especially in relation to emergency admissions.
• The shortage of crisis resolution and community treatment services as alternatives to hospitalisation.

The potential outcomes of this apparent lack of cultural competence throughout the mental health service system is summarised in the report Inside Outside (Sashidharan, 2003) which addresses mental health services for people from black and minority ethnic communities in England and Wales. Drawing on findings from a number of studies the report suggest that patients from all minority ethnic groups are more likely than white majority patients:

• To follow aversive pathways into specialist mental health care.
• To be admitted compulsorily (with significant differences also between ethnic groups at all ages).
• To be mis-diagnosed.
• To be prescribed drugs and ECT rather than talking therapies.
• To have higher re-admission rates and spend longer periods of time in hospital.
• To be assessed as requiring greater degrees of supervision, control and security.
• To be admitted to secure care/forensic environments.
• Are less likely to have their social care and psychological needs addressed within the care planning process.
• To have worse outcomes.

Beyond acute care, people from black and minority communities may be hampered by inappropriate resources to assist recovery. A study of housing and mental health care needs of Asian people in two London boroughs found that people had been placed in unsuitable high rise blocks or temporary accommodation, with insufficient support from services that were mot culturally sensitive to their needs (Radia, 1996).

There are no equivalent studies for Scotland, however, the assessment of mental health services undertaken by Grant (2004) identifies 13 areas where care for people from black and minority ethnic communities could be improved. A further illustration is provided by the report of the enquiry into the care and treatment of Mr J, a Punjabi-speaker, by the Mental Welfare Commission ( MWC) in 2002. Among other issues, the report highlights failures in communication (including inappropriate use of interpreting services), a lack of effort to identify his social or cultural needs and no consideration given to advocacy or befriending services.

Ethnicity and Mental Health: Implications

Policy drivers

There are a number of drivers for change in Scotland that extend beyond, but include the mental health service system. As indicated in Chapter 2, in addition to the
Scotland-specific Equalities Strategy, the UK-wide Race Relations (Amendment) Act 2000 places a general statutory duty on a wide range of public authorities, including health boards, to promote racial equality and prevent discrimination.

In response to the legislation the Scottish Executive Health Department published 'Fair for All: Working Together Towards Culturally Competent Services' (Scottish Executive, 2002a). This provides guidance to NHS Boards and Trusts on their responsibilities to deliver a culturally competent service, that is, a 'service which recognises and meets the diverse needs of people of different cultural backgrounds … ensuring that discrimination on the basis of culture, belief, race, nationality or colour has no role in the delivery of services' (Scottish Executive, 2002a). The guidance focuses on five strands of policy including: access, service delivery and community development.

Although not specific to mental health, the 'Fair for All' framework, and the proposed Diversity and Equality strategy for NHScotland, announced in November 2003, provide important avenues to acknowledge and respond to the specific mental health needs of people from black and ethnic minorities as well as that of other 'equalities' groups.

More specifically the principles of 'equality', 'diversity' and 'non-discrimination', embedded within the Mental Health (Care and Treatment) (Scotland) 2003 may add further momentum.

Developing a strategic approach

Despite these drivers for change there may be scope for a more strategic approach to realising the goal of redressing the mental health inequalities experienced by people from black and minority ethnic communities with the aim of:

• Making visible the issues.
• Providing a coherent statement of objectives.
• Identifying action.
• Confirming responsibility and accountability.

In England and Wales the approach has been to develop a framework for action with the aim of 'delivering race equality' in mental health ( DH, 2003b). The framework builds on the earlier Case for Action, Inside-Outside, which concluded that 'there are significant and persisting differences in and inequalities in service experience and outcome between minority groups and the majority white ethnic group' (Sashidharan, 2003, p. 16). The framework focuses on three 'building blocks' which it is proposed are fundamental to improved outcomes and experiences of people from black and minority ethnic communities:

• Better quality and more intelligently used information.
• More appropriate and responsive services.
• Increased community engagement.

Whether Scotland takes a similar approach, or locates ethnicity within a wider equalities and mental health framework, needs to be part of a wider discussion: a discussion which unpicks the commonalities across equalities groups and the specifics of, in this instance, being from a black and minority ethnic community. Two fundamental steps which, however, it is suggested need to be taken are:

• Ensuring the involvement of the different black and minority ethnic communities (including asylum seekers and refugees and Gypsy/Travellers), including people who have experienced mental health problems, in the further development of policy.
• Consideration of whether there is sufficient information on the experiences of people from black and minority ethnic communities within Scotland. Accounts and analysis of this experience draw largely on English material, but how generalisable is this to the Scottish context and are there specific dimensions to living in Scotland that are missed by relying on English experience? The experience of people living in rural and remote parts of Scotland, for example, and the implications for service delivery, may have particular salience in Scotland. Further, how might future demographic change in Scotland affect these experiences?

Elements of a strategic approach

1. Embedding consideration of mental health impacts on people from black and minority ethnic communities into other policy domains

Although largely outwith the scope of this review, the socio-economic disadvantages experienced by people from black and ethnic communities, together with the experience of racism and discrimination, suggest that policies relating to community planning/regeneration, education and training, employment, housing, criminal justice, transport, rural development etc. will have a significant and differential impact on the mental health and well-being of people from black and minority ethnic communities, including asylum seekers and refugees and gypsy/travellers.

2. Embedding equalities considerations within the mental health service system

i. Ensuring that the activities initiated under the auspices of the National Programme for Improving Mental Health and Well-Being are culturally competent.

Issues to consider might be:

• What does mental health/illness mean in different communities? What is well-being?
• To what extent do the initiatives within Choose Life reflect the patterns of suicide and self-harm among people from different black and minority ethnic communities, including asylum seekers and refugees and Gypsy Travellers?
• How is stigma and discrimination experienced by people with mental health problems from different black and minority ethnic communities?
• Given the different employment patterns of men and women from black and minority ethnic communities, what are the implications for mental health at work?
• What does building community capacity mean in the context of small ethnic minority communities within larger majority communities?
• How is the programme able to improve the mental health of younger men and women, and older men and women from different black and minority ethnic communities?
• How might the delivery of mental health improvement programmes for children and young people need to be tailored to particular groups, for example, if young women are not allowed to attend activities outside of school? How would programmes reach older people?
• What does recovery mean for people from different black and minority ethnic communities? How might this be effected?

(See for example, Tidyman, 2004; the Cares of Life Project, London, Olajide, 2004; The Chinese Mental Health Association Multimedia Mental Health promotion project, www.cmha.org.uk )

ii. Developing further capacity at primary, secondary and tertiary care health care levels to provide appropriate, timely, culturally aware and competent services responsive to meet mental health need. Capacity has a number of dimensions: developing the abilities and competence of mainstream services; developing 'specialist' services; developing the work of the voluntary and independent sector, including self-help groups. Where the appropriate balance lies between specialist and mainstream is, however, a debate that requires further airing.

A bedrock of a culturally competent service is a culturally competent workforce including, for example, social care staff and social workers, GPs and other primary health care professionals, pharmacists, psychiatrists, nurses, including Community Psychiatric Nurses, professionals allied to medicine, administrative/receptionist staff. Work is already being undertaken in this area (see for example, the NRCEMH report on the current status of cultural competency training in NHS Scotland, Pankaj, 2004), but this needs to encompass issues specific to mental health.

Monitoring, audit, inspection and performance management processes to ensure that mental health services used by people from black and minority ethnic communities do promote racial equality and prevent discrimination. This process has already started. The Mental Welfare Commission, for example, has recently completed a Race and Culture visit programme.

iii. Developing culturally competent practice

Including, for example:

• Ensuring the provision and use of appropriate interpretation and translation services. This may include consideration of the need for mental health awareness and support for interpreters.
• Developing an equalities practice, including understanding cultural identity, but also the impact of racism, on mental health and on the articulation or expression of mental distress.
• Developing appropriate assessment and diagnostic tools.
• Ensuring that services respect and respond to dietary and spiritual requirements.
• Ensuring equality of access to responsive and culturally appropriate services including advocacy, counselling, psychotherapy and befriending.
• Addressing recovery for people from black and minority communities, including access to appropriate housing, training and employment, welfare benefits, child-care.

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