The Mental Health Act is currently under independent review, with recommendations for change due to be revealed in December. MHT writers of colour have contributed their proposals as to how the new law should be shaped. Jacqui Dyer MBE, co-chair of the Independent Review of the Mental Health Act’s African and Caribbean Group, reports on how these proposals have been received.
It was encouraging to see support for the three potential new measures raised in Mental Health Today’s racial inequality poll earlier this year. The proposals provide potential answers to some big problems, albeit not new ones.
Readers gave their backing to:
- cultural awareness modules being added to all degrees related to mental health professions
- a BAME representative being involved in all risk-assessment decisions
- alternatives to the clinical model of crisis care receiving more focus, investment and development
Crisis care's complex history
Unfortunately these issues have existed for decades. While urgent, the issues are complex and as such, there is not one quick fix.
The Independent Review of the Mental Health Act is more than conscious of these issues facing Black, Asian and minority ethnic (BAME) service users. Tackling the issue of rising BAME detention rates, amid the already disproportionate number of BAME individuals facing severe mental health challenges, has been included in the review’s very terms of reference.
"Ethnicity, race and culture should always be taken into account during Mental Health Act assessments."
The Mental Health Act review’s African and Caribbean group (MHARAC), which I co-chair alongside Steve Gilbert, was established earlier in the year to specifically analyse and consider the legislation and practices that particularly impact on people of African and Caribbean descent, and to identify changes and solutions to ensure the system works in the best interests of those people. We have run extensive targeted engagement to help us understand what’s working and what isn’t. The review has set up 16 topic groups to help ensure a robust approach to analysing each of the themes identified in the review’s interim report in May 2018. These topics include ‘Addressing rising detention rates’, ‘Patient dignity and safety, ‘Advocacy’ and ‘Role of the police’. Those groups will be reporting their recommendations to the review’s Chair, Professor Simon Wessely, in September.
Will the measures backed by MHT readers make the finalised recommendations to government in December?
The suggestions from the racial inequality poll are among those being actively considered by MHARAC, and the relevant topic groups, as they work up their proposals.
We are considering how to improve competencies in working with culturally diverse groups. This requires an examination of current training across health and related professions. There is a strong rationale for effective unconscious bias training within the existing workforce so that its positive intentions are not undermined.
How can nudge and behavioural psychology theories be used to help us develop something more impactful to minimise bias and discrimination? Let’s not forget that the Mental Health Act does not exist in isolation; the Equality Act can assist us here in how we tackle discriminatory issues not only around race but also around where and how it intersects with religion, age, sexual orientation and gender.
Amplifying BAME voices in risk assessments
The poll raised the suggestion of a BAME representative being involved in all risk-assessment decisions relating to the Act. Ethnicity, race and culture should always be taken into account during Mental Health Act assessments.
Culturally-appropriate advocacy must include advocates from within the communities being served and it needs to play a greater role in providing support throughout the detention pathway.
I’m interested in the development of an advocacy model that that can be present where decisions are being made and where bias can take place. A good advocate can help to improve such decision-making processes which act in the best interests of the individual’s concerned. The intention is to contribute to a better outcome for the person’s health and wellbeing throughout the mental health crisis experience.
But I’m also concerned with the myriad of circumstances that will often lead up to a black person’s detention and treatment under the Mental Health Act. Based on the black experience thus far there is real fear and mistrust of all related services. We must tackle that if we want to minimise the all-too-common crisis route into services via the police and get closer to achieving equality of outcomes for individuals.
Preventative measures need to be in place to help build bridges between communities and services, and that will require greater cross-system collaboration – across primary care, social care and the criminal justice system, for example. This will help to ensure a more sophisticated response, and one that better acknowledges the impact of earlier negative experiences such as exclusion from school. Services would also respond more effectively if co-produced with communities; resulting in less ‘doing to’ and more ‘doing with’.
Can equality of outcomes become a requirement through MHA reform?
A Patient and Carer Race Equality Standard (PCRES) was originally recommended by the Crisp Commission. This offers an opportunity to support and hold local systems to account more robustly, to improve overall outcome for black people and other minority ethnic communities. We are looking closely as to how to make this real.
There needs to be greater representation of black people in certain professions, such as psychology, which will contribute to a more culturally-competent set of services.
The majority of the current workforce does not have personal life experience consistent with the bulk of patients that are presenting with mental health challenges. How can we also see lived experience better reflected in the development of the workforce?
We of course have to view this work in context. For example, not forgetting the work taking place at NHS England to reduce inequalities and advance equalities. The MHARAC group is developing its recommendations with that in mind, considering all of the above issues and many more, and is working with colleagues within the review team who are also prioritising these issues.
The coming weeks will see workshops in London and Liverpool on issues raised by the review so far. If you’re not able to attend a workshop, follow #mhareview on Twitter for more information about what is discussed there. Focus groups later on in August and September will then conduct detailed discussions with service users and carers in a range of in-patient and community settings, to test the review’s emerging recommendations further.
The independent review is one part of a bigger puzzle of racial disadvantage. However it is a vital, one-off chance to improve our mental health legislation and associated practice, for the future and for the service users and communities they serve. Both service users and communities have been at the heart of the review from the outset and continue to be so. This is our opportunity to get this part of the puzzle right.
Jacqui Dyer MBE is Chair at Black Thrive, Mental Health Inequalities Advisor at NHS England, and co-chair of the Independent Review of the Mental Health Act’s African and Caribbean Group.
How does this article make you feel? Share your views using #MHTchat and we'll retweet. We'll also be discussing live on Twitter at 12pm (UK time) today Wednesday 8th August.