WORKING WITH ETHNICITY, RACE AND CULTURE IN MENTAL HEALTH doc

WORKING

WITH

ETHNICITY, RACE

AND CULTURE

IN MENTAL HEALTH

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Working

with

Ethnicity, Race

and Culture

in Mental Health

A Handbook for Practitioners

Hári Sewell

Jessica Kingsley Publishers

London and Philadelphia

First published in 2009

by Jessica Kingsley Publishers

116 Pentonville Road

London N1 9JB, UK

and

400 Market Street, Suite 400

Philadelphia, PA 19106, USA

www.jkp.com

Copyright Hári Sewell 2009

For further information please visit www.harisewell.com

All rights reserved. No part of this publication may be reproduced in any

material form (including photocopying or storing it in any medium by

electronic means and whether or not transiently or incidentally to some

other use of this publication) without the written permission of the

copyright owner except in accordance with the provisions of the Copyright,

Designs and Patents Act 1988 or under the terms of a licence issued by

the Copyright Licensing Agency Ltd, Saffron House, 6–10 Kirby Street,

London EC1N 8TS. Applications for the copyright owner’s written

permission to reproduce any part of this publication should be addressed to

the publisher.

Warning: The doing of an unauthorised act in relation to a copyright work

may result in both a civil claim for damages and criminal prosecution.

Library of Congress Cataloging in Publication Data

A CIP catalog record for this book is available from the Library of Congress

British Library Cataloguing in Publication Data

A CIP catalogue record for this book is available from the British Library

ISBN 978 1 84310 621 0

ISBN pdf eBook 978 1 84642 855 5

Printed and bound in Great Britain by

Athenaeum Press, Gateshead, Tyne and Wear

To Jacqui Dillon, my Rock. My constant. Thank you for creating so much

from so little.

To my precious and absolutely stunning sons James-Earl and Aaron.

Thank you for giving me so much love and support to get to the end of this

project.

Dara and Sia. Thank you for the affection and the space.

Lorenzo and Hazel Sewell. You are the explanation most people seek

from me.

Acknowledgements

Thanks to my colleagues who have rehearsed these ideas with me for 15

years. Your influences are reflected here: Errol Francis, Sue Holland, Suman

Fernando, Yvonne Christie, Melba Wilson, Sharon Jennings, Sandra

Griffiths, Malcolm Phillips, Frank Keating, Parimala Moodley, Lennox

Thomas, Olivia Nuamah, Kwame McKenzie, Barbara D’Gamma.

To those who were critical in setting high standards: Martin Smith, Jo

Cleary.

And to Francesca Russo, Peter Gilbert, James Sandham and Geoff

Alltimes.

Contents

Foreword by Dr Suman Fernando 11

1. What is ‘Ethnicity, Race and Culture’? 13

Definitions 13

Race 14

Ethnicity 17

Culture 19

The problem with race 21

Institutional racism 22

Nomenclature – black and minority ethnic groups 25

Conclusion 25

2. Why are Ethnicity, Race and Culture Important

in Mental Health Services? 26

Legislation and policy 26

The implications of variations: Ethnicity, race and culture

in mental health 29

Hypotheses about causes of variations 31

Toxic Interactions Theory – a new perspective 34

Relationships between areas of variation 37

Taking ethnicity, race and culture into account as a practitioner 39

Conclusion 43

3. Quality Assessments 44

Components of an assessment 45

Ethnicity, race and culture and the assessment process 46

Racism Diagnostic and Review Tool (RaDAR Tool) 52

Conclusion 55

4. Recovery-focused Care Planning 56

Definition 56

Conflicts with the recovery-focused approach 57

Implementing recovery-focused care planning 57

Conclusion 69

5. Quality Relationships in the Delivery of

Care Plans 72

Rationale for focusing on the relationship 74

Trust 76

Obstacles to effective relationships 77

Speaking about race and racism 82

Conclusion 88

6. Ethnicity in the Context of Other Identities 89

Sexuality 89

Mixed heritage 96

BME children brought up in white families or in public care 101

Gender 104

Disability 112

Making complexity manageable 114

Conclusion 123

7. The Role of the Team Manager 124

Business and performance management of the team 124

Management of individual team members 130

The role of the manager as an advocate 143

Conclusion 144

8. The Role of the Training, Education, Learning

and Development Department 145

Developing competence 145

Informing organisational strategy 147

Developing the knowledge and skills of the workforce:

Getting from A to B 148

Defining competence 150

Responding to gaps: The content of education, learning

and development 153

Getting from A to B: Applying the different approaches 157

Conclusion 157

9. Considering Alternatives to the

Illness Model 159

Psychiatry and race 161

Faith and religion 162

Hearing Voices Approach 164

Trauma approaches 165

Recovery Approach 169

Explanatory models 170

Alternative models and the impact on practice 170

Conclusion 171

10. Positive Examples of Doing it Differently 172

Exploring examples of positive practice 174

Conclusion 181

11. Conclusion 182

References 184

Subject Index 196

Author Index 206



1.1 Race, ethnicity and culture 13

1.2 Language of discrimination 22

2.1 Utilisation of different services 38

3.1 Critical analysis of referrals for black people 48

3.2 Critical analysis of referrals for Asian and other

minority ethnic groups 51

4.1 Template: Working towards recovery with service users 70

6.1 Sewell’s Seven Elements for Strengthening Practice 116

7.1 Evaluation of team performance 127

7.2 Template: Identifying and Responding to views of

minority groups 129

8.1 ERC competencies 151

8.2 Template: Matching development methods to competencies 158





1.1 Institutional racism 23

5.1 The 4 Ps in the therapeutic relationship 73

5.2 Relationship as the container for change in the 4 Ps 74

Foreword

The past few years have seen many books commenting on the failure of

mental health services to meet the needs of black and minority ethnic

people. Some highlight the effects of racism – especially ‘institutional

racism’ – while others emphasise the lack of sensitivity to cultural difference

in the ways of working, especially the ‘medical model’ of (Western) psychia￾try on which services are generally based. Government plans to address the

problems top-down appear to try riding both horses, but all too often fall

between them or fall off both.

What is happening at the coal face of mental health care is that profes￾sionals are left searching for ways forward, trying to meet the proper and

just expectations of culturally diverse service users, trying not to be racist in

practice, and endeavouring to improve the quality of service that they

provide. Going back to school, studying the faults in the systems they are

supposed to work with, analysing their own capabilities, undergoing

training to become ‘culturally competent’ (whatever that means) and so on,

are not really options for most busy people under pressure. They have to

make do, learn a bit about issues to do with race, ethnicity and culture, how

an ideal system should work and try to understand how their own practices

can contribute to ensuring that the service is improved for everyone. This is

where this book by Hári Sewell comes in. This is a book for practitioners –

essentially a self-training book but also one that could be used as a source of

knowledge in a complex and controversial field.

The author knows about the realities at the grass roots, how NHS

mental health care is currently set up, what types of approach are practicable

and what are not and he understands what busy practitioners may look for

in a book called a ‘handbook’. What he has done is to digest the literature,

think about matters, connect with service users, talk with managers and pro￾fessionals and then provide readers with a succinct account geared towards

helping practitioners to change their practice – indicating how and why

these changes can make a real difference.

This book discusses all the main aspects of terms used in the field of

mental health care in relation to a culturally and racially diverse population.

It then delves into practical matters – assessments, recovery focused care and

11

so on, providing clear practical guidance on implementation, illustrated by

concrete examples from real life and many case descriptions. Most impor￾tantly the book provides evidence and a rationale for every suggestion that

is made, indicating the author’s wide ranging knowledge and grasp of the

topics discussed. The tables and illustrations help to focus effectively on the

main aspects of what the author is trying to convey. This is a book directed

to people working at ground level in mental health services where the

action takes place – a very practical book informed by common sense, a

wealth of knowledge and clear thinking.

Dr Suman Fernando,

European Centre for Migration and Social Care (MASC),

University of Kent.

12 / WORKING WITH ETHNICITY, RACE AND CULTURE IN MENTAL HEALTH

13

Chapter 1

What is ‘Ethnicity,

Race and Culture’?

Language conveys many things; some intended and others not. An attempt

to achieve precision in the use of terms specific to any area of study can be

viewed as pedantic or futile. Terminology develops as a means to establish a

shared understanding but people intend or hear different meanings. This

chapter sets out definitions of ethnicity, race and culture (ERC). The aim is

to establish a common understanding between author and reader about the

intended meanings for terms used in this book.

A lack of precision in understanding terms and concepts leads to confu￾sion and poorer response to need. For example, a focus on culture in a

context where race (and racism) is the issue, fails to address the real problem

appropriately.

Fernando (1991) provides a succinct description of the difference between

ethnicity race and culture. His helpful chart is reproduced in Table 1.1:

Table 1.1 Race, ethnicity and culture

Characterised by Determined by Perceived as

Race Physical

appearance

Genetic ancestry Permanent

(genetic /

biological)

Culture Behaviour

Attitudes

Upbringing

Choice

Changeable

(assimilation,

acculturation)

Ethnicity Sense of

belonging

Group identity

Social pressures

Psychological need

Partially

changeable

(Fernando 1991, p.11)