Tackling inequalities: a partnership between mental health services and black faith communities

Background

In October 2017, the UK Prime Minister announced a review of the Mental Health Act in England. In the announcement, the fact that people from Black and minority ethnic groups (BAME) are four times more likely to be detained under the Act than White British groups (Care Quality Commission, 2018) was acknowledged. This has been described as the country’s “dirty secret” (Mulholland, 2017) and urgently needs addressing.

The reasons for this disparity have been long debated. Some argue that it is a function of higher rates of serious mental illness in this group (Gajwani, Parsons, Birchwood, & Singh, 2016), which may be driven by social determinants of poor mental health and structural discrimination of minorities outside of the health system. However, determining the seriousness of mental illness involves a risk assessment, which may be coloured by prejudice and the notion of the Black person as “big, black and dangerous” (Mulholland, 2017). Others argue that detention rates are higher due to later presentation to health services. Whilst there is some evidence for this in the US (Sohler, Bromet, Lavelle, Craig, & Mojtabai, 2004), this finding has not been replicated in multiple UK cohort studies (Ghali et al., 2013; Morgan et al., 2006). What has been shown in the UK is that individuals from BAME groups are more likely to enter mental health services through the criminal justice system than through primary health care (Ghali et al., 2013). In addition, the longitudinal trajectory of psychosis in Black service users typically has longer periods of admission and compulsory re-admission (Ajnakina et al, 2017).

There are other examples of mental health inequalities for the BAME group. People from ethnic minorities are less likely than their White British counterparts to have contacted their general practitioner (GP) about mental health concerns, to be prescribed antidepressants, or to be referred to specialist mental health services (Memon et al., 2016). Indeed, a recent report highlighted the underutilisation of services by BAME groups who are hard to reach due to linguistic and cultural barriers (NICE, 2017). Such failures by the professional health services plausibly leads to fear and mistrust in the community, perpetuating a cycle of poor access and increased requirement for coercion.

The role of community interventions and black majority churches

Tackling these health inequalities and mistrust within the community will require an approach that considers prevention alongside improved access and experience of mental health services for BAME groups. To achieve this, health professionals need to work alongside members of BAME communities to co-produce interventions and services that are acceptable. Crucially, the process of co-production and community ownership may lead to increased trust in professionals and demand for services, so long as the programme increases mental health awareness and reduces stigma. Evaluation of the national anti-stigma campaign Time to Change has demonstrated improvements in public attitudes and stigma-related knowledge over time (Henderson et al., 2016). However, at least initially, the same improvements were not seen in BAME groups (Time to Change, 2010). Interestingly, when Black champions became engaged in the campaign, then stigma reduction accelerated among Black members of the general population. Similarly, the Black Health and Wellbeing Commission for Lambeth, South East London, wrote a series of recommendations based on the re-evaluation of the needs of the local African and Caribbean population following the death of Sean Rigg, a 40 year old man with schizophrenia, who died following police restraint in 2008. Within this, they recommended the Well London Health Champions programme and the proven benefit of having community champions integrated within mental health services (Lambeth Black Health and Wellbeing Commission, 2014).

In this editorial, we focus on the possible role of Black faith organisations as partners for a community led stigma intervention. In London, the borough of Southwark has the greatest concentration of African Christianity in the world outside Africa (Rogers, 2013), with an estimated 20,000 people gathering to worship in 240 different Black majority churches each week. Through these organisations, there is huge potential to reach members of the Black community in order to open up channels of communication, improve mental health awareness and reduce barriers to help-seeking. However, research indicates that BAME service users consider a positive relationship with their faith as central to wellness, rather than adopting a medicalised view of care (Codjoe et al., 2013). Therefore, the success of such a programme will require sensitivity and understanding on the part of mental health professionals to different cultural and religious beliefs, and how these relate to knowledge, attitudes and behaviours towards mental health.

We will present the current evidence for mental health knowledge, attitudes and behaviours of Black faith communities in the UK, including some of our own unpublished scoping work. We will also introduce a developing partnership between mental health services and faith communities in Lambeth and Southwark, South London as an example of a co-produced community intervention that strives to be culturally informed, sensitive and trustworthy.

Knowledge about mental health and mental illness

“Knowledge” is not a straightforward concept in mental health. Explanatory models for mental illness vary widely and are culturally enshrined and create challenges for the delivery of professional mental health services. Mantovani and colleagues conducted focus groups with members of Black faith communities in South London and one participant explained: “Mental illness, as somebody who comes from Africa, we think it’s a curse. We think you’re possessed by the devil” (Mantovani, Pizzolati, & Edge, 2017, p. 376). Explanatory models are believed to play an important role in help-seeking – specifically, “if illness is thought to be a punishment requiring spiritual expiation then medical intervention is less likely to be considered” (Leavey, Loewenthal, & King, 2016, p. 1609).

Knowledge that goes beyond explanatory models and encompasses services, treatment and recovery is often called mental health literacy. The Mental Health Knowledge Scale (MAKS) is a validated tool that has been used to evaluate the impact of the national anti-stigma Time to Change campaign on mental health literacy (Evans-Lacko, Henderson, & Thornicroft, 2013). We have applied this scale to 62 members of Black majority churches in South London and found that only 51% agreed that “most people with mental health problems go to a healthcare professional to get help”. When we compare this to results from the survey of 1700 members of the general public, the results were the same (51%) (Evans-Lacko et al., 2013), highlighting the challenges that exist across the whole population to normalise professional mental health care. Interestingly, whilst our participants appear less likely to agree medication can be effective (69.4% vs. 78.4%), a higher percentage agreed that psychotherapy can be effective (92% vs. 80%) and that people with severe mental illness can fully recover (70% vs. 60%) compared to the general public data.

There are limitations to what can be concluded from this comparison (this is not age-matched or gender-matched sample). However, this data supports our belief that a productive partnership between faith organisations and professional mental health services is possible. In particular, data from our follow-on focus groups suggested that individuals can hold multiple views: All the demonic possession symptoms are similar to mental health crisis… I think the difference, for me, is having the information and being open to applying both schools of thought (unpublished data). This is supported by other qualitative studies where crucially faith leaders have said: We do believe in spirits’ influence on people’s mind and behaviour but not in everything (Mantovani et al., 2017, p. 380). Of course, some religious conceptualisations of mental illness pose challenges to health professionals applying the medical model, but if both partners can promote parallel thinking in their practice collaboration is likely to be more successful.

Attitudes towards people with mental illness

The BAME population in the UK is vast and diverse, with likely varying attitudes towards mental health. Through published qualitative studies and our own scoping data, we have built a preliminary picture of the attitudes towards mental health in Black faith communities in South London. We emphasise that this editorial takes a narrow view of one population and does not assert that these attitudes are unique. One particular theme that stands out as a target for a community stigma intervention is that of weakness or moral failing. A focus group participant in Mantovani’s recent study explained, You don’t have enough faith. You don’t have enough belief in God (Mantovani et al., 2017, p. 377). In our own focus groups, participants have said, If you are unwell you are something less, what you contribute is of less value, and my community believes that mental health is a weakness (unpublished data). It is possible that attitudes relating to weakness and shame lead to secrecy and reluctance to seek help until symptoms are severe resulting in increased likelihood of entering care through coercive routes. Certainly, members of this population are fearful of this possibility: They will lock you up and when they lock you up that’s it (unpublished data).

Behaviour towards people with mental illness

Behaviour towards people with mental illness results from attitudes which are entrained by knowledge (Thornicroft, 2006). The behavioural consequences of negative attitudes can result in a desire for social distance (intended behaviour) (Henderson et al, 2016). Within the Black community, as in almost all communities worldwide, those people with mental health difficulties may sometimes be ostracised or isolated. In the words of one focus group member: You are rejected by your own community, by your own environment (Mantovani et al., 2017, p. 377). Alongside the MAKS above, we applied the Reported and Intended Behaviour Scale (RIBS) scale to our small sample of Black majority church members. The RIBS is a brief questionnaire designed to assess reported and intended stigmatising/discriminatory behaviours. In our sample, only 27% agreed they would be “willing to live with someone with a mental health problem”, 57% were willing to work with someone, 56% were willing to live nearby to someone and 66% would be willing to continue a friendship with someone with a mental health problem. This demonstrates a desire for social distance, which we know impacts not only on the person with a mental illness, but also the whole family through association (Corrigan & Miller, 2004).

Additionally, studies have shown that equating mental health problems only with severe mental illness is likely to result in greater stigma and social distance toward the mentally ill (Broussard et al., 2012). Qualitative studies have shown that members of Black faith communities may not view mental health on a continuum: …our perception of mental illness is somebody’s totally derailed and is walking in the street, probably naked (Mantovani et al., 2017, p. 376). Focussing on a continuum explanation may improve not only knowledge, but also attitudes and behaviours towards people with mental illness (Corrigan et al., 2017).

Building partnerships between communities and health services

To co-design acceptable and sustainable programmes to reach BAME communities, it is vital to understand the specific issues around knowledge, attitudes and behaviours towards people with mental illness in this group. Members of Black faith communities in South London appear to have explanatory models of mental illness that are coloured by their religious and cultural backgrounds. It is also possible that the image of a person with mental illness is towards the extreme, which may impact on attitudes and behaviours. This could be reduced by a mental health awareness programme that frames mental health on a continuum (Corrigan et al., 2017). There is also narrative emerging from qualitative studies that people with mental illness may be perceived as weak, which may lead to a desire for social distance from people with mental illness. We know from the wider stigma literature that increasing contact with people with mental illness reduces the desire for social distance (Couture & Penn, 2003). In addition, community leaders may be called upon to challenge the notion of moral failing in mental illness.

The ON TRAC project, funded by the Guy’s and St Thomas’ Charity, is a collaborative partnership between Kings’ College London, South London and Maudsley NHS Foundation Trust and Black faith community groups in Southwark and Lambeth. Evidence-based short course teaching modules will be developed for the training of Mental Health Champions, nominated members of church congregations who will act to promote mental health awareness and signpost individuals and families to services. This aims to improve mental health literacy and access to support. The project will also create a register of trained Faith Consultants, who have a leadership role within their community and can offer advice to health professionals seeking to provide culturally informed care. Finally, by designating Faith Community Lead staff within SLaM, there is an acknowledgement of the importance of cultural competency within an organisation. This cannot be tokenistic, but instead requires long-term commitment to work closely with the community that it serves. In the long term, this partnership aims to promote mental wellbeing, increase access and improve the experience of mental health services by BAME groups.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

GT is supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South London at King’s College London NHS Foundation Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. GT acknowledges financial support from the Department of Health via the National Institute for Health Research (NIHR) Biomedical Research Centre and Dementia Unit awarded to South London and Maudsley NHS Foundation Trust in partnership with King’s College London and King’s College Hospital NHS Foundation Trust. GT is supported by the European Union Seventh Framework Programme [FP7/2007-2013] Emerald project. GT also receives support from the National Institute of Mental Health of the National Institutes of Health under award number R01MH100470 (Cobalt study). GT is also supported by the UK Medical Research Council in relation the Emilia [MR/S001255/1] and Indigo Partnership [MR/R023697/1] awards. LC is supported by Guy's and St Thomas' Charity in relation to the ON TRAC project [EFT151101] award. SB is supported by the King's College London Academic Foundation Programme.