Could 2018 be the year ethnic minorities begin to see progress in crisis care outcomes? Professor Nisha Dogra discusses the work she's leading at the Royal College of Psychiatrists on equality, diversity and inclusion.

Understanding the causes and contexts of someone’s illness is crucial in treating mental illness.

That’s why it’s so important for psychiatrists to understand the links between culture and mental health and to be able to comprehend how their own values and beliefs may lead to a radically different perception of ‘normal’.

"At Leicester University, we have moved medical students from having standalone diversity training to incorporating it throughout all aspects of training... This is not about attempting to learn specifics about each and every culture, rather about taking time to ask patients the right questions in order to be able to provide care appropriate to them."

As the Royal College of Psychiatrists’ Associate Dean for Equality, Diversity and Inclusion, my role to is to improve our members’ – 18,000 psychiatrists’ – understanding of how our own sense of culture and experience influence our world view. We need to understand how our own biases may influence the way we provide care and act on this to improve the experience of our patients.

Much of my work focuses on psychiatrists’ education and training – ensuring that psychiatrists incorporate cultural aspects into all areas of their work. More widely I want to ensure that diversity runs through all the work of the College including training and the examinations.

Psychiatry embraces people from all walks of life and racial and cultural backgrounds. Of all medical professions, psychiatry has the highest proportion of training doctors who have graduated overseas. Indeed, coming into medicine from other backgrounds is welcome because it gives you an alternative viewpoint which can help you to see the ‘person behind the label’.

It's comfortable to fall back on assumptions

Too often we make assumptions about people based on their diagnosis or other characteristics (their ‘label’). If someone with a mental illness attends A&E we know they can receive poorer care than for those with physical problems. I can’t count the number of times I have seen young people who have self-harmed and have been told that they don’t warrant care in the emergency department as it is for people who “really” need our help.

The same can be true of race and cultural background.

As one patient said in a focus group: “What the psychiatrists may understand as out of order and therefore psychotic exhibitions of mental disorder, to one in his own understanding of the world, according to his culture, is not madness at all.”
This is not a problem exclusive to psychiatry – anyone can struggle to see things from another person’s perspective, whether in or out of their working lives.

That is why our former president Professor Sir Simon Wessely’s work reviewing the Mental Health Act is so important - it is scandalous that a disproportionately high number of young, black men are detained under the Act.

But as Sir Simon said in the interim report of his findings published earlier this month, there’s no quick fix [Editor's note: these are three ideas from people of colour]. The multiple, complex interrelated identities which we all have are subtly altered in different contexts. Often this can be forgotten about when patients are seeking help, or overlooked.

During my own periods of illness (osteosarcoma, a type of bone cancer) so many assumptions have been made about me and what I must be feeling and thinking.

Rarely did these assumptions reflect my experiences, or even come close.

It was assumed that alopecia was the worst thing about being ill and having chemotherapy and it really wasn’t.

When medical students are taught about diversity in medical schools, there is often a tendency to guide people towards treating people with similar characteristics homogenously.
Medical students often expect to be taught to have definitive answers on how to treat different ethnic groups, people with disabilities, different religious groups and so on.

What happens when a patient falls into two or more boxes as they usually do? Which comes first?

My own deafness and cancer have taught me that while I might share some features with other people who are deaf I am also very different because there are a whole range of other factors, personal to me. Assumptions about gender have been more obvious than about my ethnicity and I suspect most of my health care providers did not even realise I was hard of hearing.

These experiences mean that as a doctor, especially as a psychiatrist, I consciously avoid making assumptions about individual patients, how illness might impact them and how they may manage life events. But I need to keep reminding myself to do that as it is so easy to fall back on what is comfortable.

Pursuing a patient-centred approach to diversity education

There are systemic issues specific to ethnicity and mental health that need to be tackled with a truly systemic approach, especially for black people who are over-represented in acute mental health services and less likely to benefit from preventative services.

The Royal College of Psychiatrists’ recent position statement on racism and mental health is an important starting point with its recommendations including introducing a Patient and Carers Race Equality Standard, which would measure treatment of BME patients and require health care providers to develop and implement plans for improvement and appointing a cross-government equalities champion.

In my College role, I advocate for a patient-centred approach to diversity education for mental health staff. Patients should be truly listened to, and heard, rather than feeling judged and assumptions being made about them.

Those who provide mental health services need to be aware of subtle, but important, differences that are needed when caring for patients they may have pre-established views of based on any characteristic. This means not stereotyping them or basing their care on a single characteristic but seeing the whole person.

This is not about attempting to learn specific information about each and every culture, rather about taking time to ask patients the right questions in order to be able to provide care appropriate to them.

My medium-term goal - by 2020 - is to work with the College to review training materials and training opportunities to ensure psychiatrists incorporate cultural aspects across their work. Psychiatrists should feel supported to reflect their own perspectives, behaviours and understand the role their biases (conscious and unconscious) may have on the care they provide, and to challenge inappropriate behaviours.

Equality, diversity and inclusion training has been mandatory for psychiatrists for over a decade. This means training to avoid stereotyping patients or basing their care on a single characteristic and instead to see the whole person.

At Leicester University, we have moved medical students from having standalone diversity training to incorporating it throughout all aspects of training. Much of our training is delivered through group work to explore where participants’ own attitudes come from and how they are formulated. Such self-explanatory work really is critical in understanding views and how care should be tailored accordingly.

While such training has variable content and quality and is not short of criticism (from doubts around its value to claims that it is tokenistic) some training has been shown to lead to more open attitudes in medical students and understanding that we all have biases which need to be acknowledged as they influence the care we provide.

It “highlighted stereotypes I didn’t know I had” said one student. “It provides real life context and made me ask myself whether or not I made enough challenges [to my own assumptions].”

This change in student attitudes measured by pre- and post- training questionnaires is so encouraging.

Meanwhile, cynicism that exists amongst professionals around equality and diversity is a key hurdle to cross. Failing to do so risks losing the progress made in the mindset of medical students when they join the wider workforce.

And it is important that the Royal College of Psychiatrists itself is a leading example. The College will update its equality, diversity and inclusion policy over the next six months. I hope to hear from a wide range of colleagues to inform this work. Even more importantly, the College will identify how best to communicate to its members and staff and for this to be transparently monitored.

Progress won’t come easy and may be hard to track. To continue to improve and engage everyone in this we need to monitor our work and identify actions that lead to positive change and the reasons they worked. Ensuring that patients receive help that sees beyond stereotypes requires more than another piece of paperwork on the shelf. We need change in how we approach diversity and inclusion within organisations.

In the words of one medical student: “we all hold stereotypes and make assumptions and this is fine but the important factor is that we challenge these.”

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