Black Caribbean people experience persistent inequalities in accessing mental health services; for instance, those with psychosis are more likely to access mental health care via the police than White British people (Halvorsrud et al., 2018). This higher number of involuntary admissions among Black Caribbean people may contribute to increased reluctance to seek help (Islam et al., 2015) and mistrust towards mental health services (Henderson et al., 2015). Furthermore, Black Caribbean individuals with psychosis encounter worse clinical, social, and service use outcomes from their first presentation to services up to 10 years later than their White counterparts (Morgan et al., 2017).
A study by Lawrence and colleagues (2021) explores the lived experience of accessing mental health services from the perspective of both Black Caribbean and White British people, helping us to understand how inequalities in accessing mental health care among different ethnic groups are experienced and sustained.
This article details a qualitative study that purposively sampled 17 Black Caribbean, 15 White British, and three non-British White individuals who were in contact with mental health services for first-episode psychosis.
The qualitative study was embedded in a larger multi-ethnic cohort study (Morgan et al., 2017). Eligibility criteria included participants who were (1) between 16 to 64 years of age; (2) from Southeast London, Bristol, and Nottingham; (3) in contact with mental health services for first-episode psychosis, which was not as a result of an organic medical reason and not accompanied by a learning disability; (4) experiencing hallucinations, delusions, thought disorder, disturbed behaviour, negative syndrome, mania or clinical suspicion of psychosis and (5) not previously in contact with mental health services for psychotic symptoms.
In-depth interviews were facilitated by a White male academic who asked open-ended questions, which prompted participants to reflect on their journey through mental health services. Each interview was approximately one to two hours. The interviews were analysed using thematic analysis, informed by a narrative experience-centred research approach. The latter recognises the importance of uncovering ideologies whilst individuals tell their stories.
The researchers reflected on how their own experiences may have influenced the interpretation of participants’ accounts.
The article highlighted five aspects of accessing mental health services and how these differed between Black Caribbean and White British/non-British individuals.
Entering mental health services
Two-thirds of White British participants discussed how they voluntarily entered mental health services and typically had a support system. Contrarily, most Black Caribbean individuals’ admission involved the police, who were contacted by individuals within their community.
Black Caribbean individuals discussed their preconceived notions regarding mental health care for people of colour, which provided insight into possible reasons they are less likely to seek mental health care. For example:
…you know people of colour being put into mental health, being wrongly diagnosed… I was just… terrified.
Inpatient unit admission
Black Caribbean individuals recounted painful memories when first entering inpatient mental health units, for instance, not being appropriately communicated to by staff members, leading to confusion, agitation, and feelings of powerlessness. This had a long-lasting effect during their stay, as depicted in the following quote:
From then I couldn’t talk to anyone, I didn’t feel I could trust anyone….
This group further believed there was a lack of collaboration with staff. One individual discussed that he felt he was unfairly admitted since he was managing his symptoms well. White British people discussed a similar feeling, in that even if they were voluntarily admitted into the inpatient units, once there, they felt that they had no freedom.
Inpatient ward experience
Many women participants reported having positive relationships. However, some did speak about not being informed of information from staff regarding themselves, which contributed to feelings of disempowerment. Most individuals spoke about how they experienced a loss of freedom and felt restrictions within inpatient wards were excessive. Further, every Black Caribbean woman said that there were not enough Black doctors, leading to feeling misunderstood.
There were noticeable differences between White British/non-British and Black Caribbean people regarding social and material resources. Many White individuals had resources that allowed alternative care arrangements. In contrast, many Black Caribbean individuals did not have this privilege, resulting in feelings of being trapped: “Yes that’s my prison of course it is.”
Positioning of medication
Participants discussed how they felt forced to take the medication, resulting in feelings of powerlessness. However, some White British individuals were able to discuss with staff the medication dosage collaboratively.
Many people accounted feeling a diminished sense of self resulting from side-effects of medication and how they would stop taking their medication in the community, often resulting in worsening symptoms and subsequent hospital admissions. However, a few discussed that they were committed to taking their medication when they found the appropriate medication dosage.
Attitudes towards diagnosis
Most individuals discussed feeling there was a lack of collaboration regarding their diagnosis. Many felt the diagnosis was an oversimplification and not helpful, as they felt them be a normal reaction to stressors within their lives. However, some used their diagnosis to reclaim control and took it upon themselves to research what the label meant.
Further, Black Caribbean individuals generally felt that psychiatry did not consider culture; for example, one participant said:
My critique of psychiatry… a lot of… it’s a narrow perspective of life.
There are apparent differences between Black Caribbean and White British service users regarding their experience of first contact with mental health services, first hospital admission, inpatient wards and their view of both medication and diagnosis. Throughout all these experiences, Black Caribbean individuals recounted more negative feelings, particularly powerlessness, than their White counterparts.
Strengths and limitations
This is the first study assessing how inequalities experienced across different ethnic groups when accessing mental health services affect people living with psychosis. A better understanding of these inequalities may inform strategies on how to address and reduce them.
A total of 32 participants limits the generalisability of the findings obtained. Additionally, individuals were either from Southeast London, Bristol, or Nottingham; therefore, these results may not apply to those from rural areas of England or other countries.
A White male academic carried out the interviews with both White and Black participants. Research has demonstrated that Black researcher-Black participant dyads during qualitative research tend to ease the emotional burden of telling racism stories through a sense of shared understanding (Mizock et al., 2011). Therefore, there is a potential that Black Caribbean participants may have responded differently if an individual with a shared racial identity had carried out the interviews. Relatedly, the data analysis was conducted by three different White researchers, which may ensure a more comprehensive analysis; however, the lack of ethnic diversity between the researchers may have limited the interpretation of the data.
Implications for practice
Involuntary admissions followed by the lack of communication and a power imbalance between mental health professionals and service users can hinder respect for the service users’ rights, will and preferences, worsening feelings of marginalisation. Mental health staff should listen, share information, be aware of their power and make joint decisions with the service users. The least restrictive approaches should be used, and mental health professionals should encourage service users to take more ownership of their care plan, possibly leading to better outcomes.
Considering that Black Caribbean people were offered less social and material resources than White British individuals, mental health staff could be additionally trained on the importance of offering equal resources to all service users. To ensure the provision of culturally adapted resources, services should evaluate the suitability of resources for everyone with different racial identities. This may highlight existing gaps and underline the need to develop new resources. Mental health professionals may also benefit from reflective discussions exploring why fewer resources are provided to Black Caribbeans. It will also be important to acknowledge the ways in which white privilege manifests in mental health professionals and in their interpersonal reactions. This can encourage the adoption of an anti-racism practice that accounts for the racism shaping the clinical encounter and the racial oppression present in mental health care leading to a more transparent and accountable clinical practice.
Moreover, service users should be informed about the type of medication prescribed and its potential benefits and side effects. Mental health professionals and service users should jointly decide, where possible, on reducing their medication dose or switching to alternative treatments. This can enhance feelings of empowerment among service users, resulting in higher treatment adherence.
Statements of interests
Lawrence, V., McCombie, C., Nikolakopoulos, G., & Morgan, C. (2021). Ethnicity and power in the mental health system: experiences of White British and Black Caribbean people with psychosis. Epidemiology and Psychiatric Sciences, 30.
Morgan, C., Fearon, P., Lappin, J., Heslin, M., Donoghue, K., Lomas, B., Reininghaus, U., Onyejiaka, A., Croudace, T., Jones, B, P., Murrary, M, R., Doody, A, G., & Dazzan, P. (2017). Ethnicity and long-term course and outcome of psychotic disorders in a UK sample: the ÆSOP-10 study. The British Journal of Psychiatry, 211(2), 88-94.
Mizock, L., Harkins, D., & Morant, R. (2011). Researcher interjecting in qualitative race research. In Forum Qualitative Sozialforschung/Forum: Qualitative Social Research (Vol. 12, No. 2).
Islam, Z., Rabiee, F., & Singh, S. P. (2015). Black and minority ethnic groups’ perception and experience of early intervention in psychosis services in the United Kingdom. Journal of Cross-Cultural Psychology, 46(5), 737-753.
Henderson, R. C., Williams, P., Gabbidon, J., Farrelly, S., Schauman, O., Hatch, S., … & MIRIAD Study Group. (2015). Mistrust of mental health services: ethnicity, hospital admission and unfair treatment. Epidemiology and psychiatric sciences, 24(3), 258-265.
Halvorsrud, K., Nazroo, J., Otis, M., Hajdukova, E. B., & Bhui, K. (2018). Ethnic inequalities and pathways to care in psychosis in England: a systematic review and meta-analysis. BMC medicine, 16(1), 1-17.