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Live Chat about black British mental health issues |
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The All in the Mind live webchat about the way black British people are treated in the mental health system has now finished. Thanks to everyone who sent in questions for Dr Raj Persaud and his guests, Dr Kwame McKenzie and Paul Grey.
We had a great response - there just wasn't time to answer them all. Read the full transcript below.
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Question 1
From Chris Burford:
Paul Gray wrote about the power of love. It was heart-warming for me as a psychiatrist to hear Paul tell how he had been able to free himself from the mental health system.
My questions are:
1) How can we have alternatives to the ward round system so that other staff can do what they can to help without having to wait for the psychiatrist to take the big decisions, so as to keep hospital use to the minimum.
2) How can psychiatrists really listen to people about their problems if their questions are above all designed to classify people according to categories of diagnosis? What are psychiatrists going to do if they do not make diagnoses?
Paul Grey
One of the ways would be to have someone who had a relationship with the individual and they could feed the information back to the team - considering that psychiatrists only get a short time with each patient. A relaxed atmosphere when possible, in a cafΓ©, a community setting or the person's home.
Kwame McKenzie
It would be a shame if all psychiatrists did was to make a diagnosis. Most clients want help with a number of problems, making a diagnosis only a small part of the management of any problem. Perhaps the questions need to be geared towards people's real difficulties in life rather than psychiatrists' preoccupations.
Question 2
From Julia Smith:
Thank you for this helpful programme. I was so encouraged to hear the emphasis on respect for those with mental health problems and the need for them to be fully in control of their treatment. How far do you think this principle is recognised among psychiatrists?
Dr Kwame McKenzie:
The pressure on psychiatrists is for the safety of the patient and society. Because psychiatrists are investigated every time there's a problem, they tend to be very cautious. It would be difficult to change that atmosphere and make psychiatrists less scared. Psychiatrists recognise the principles of a partnership in management but there's a difference between recognising it and doing it.
Question 3
From Liza Neville:
I am currently supporting a young man who faces a charge of arson. He has spent most of his life in care and is now 24. No-one has given him a diagnosis - most likely he has a borderline personality disorder - he has spent two and a half years fighting the mental health system to try and get some help, and in the absence of any pro-active services often ends up calling 999 for an ambulance, or wondering around on the motorway until the police pick him up.
Can you tell me whether this young man is being discriminated against becasue he is a care leaver, becasue he lives in poverty in the wrong part of town, or becasue - like so many young adults in need of help and support - he just doesn't fit easily into anyone's pigeonhole ('not diagnosably treatably mentally ill' is the usual get out ), or is he discriminated against primarily because of his colour?
Will the new Mental Health Act make it easier, or even more difficult for people with enduring mental health problems to get the help and support to which they are entitled?
Dr Raj Persaud:
Thanks for your question - I suspect you are an extremely important resource for this young man. He really needs a proper assessment by a psychiatrist or a psychologist - in particular a Forensic Psychiatrist - there are a few who specialise in fire-setting in particular. So it would be really useful to suggest to his lawyer that they get an assessment from such a Forensic Psychiatrist. The psychiatrist can then make a recommendation to the court and these reports have a lot of sway and can usually prevent a custodial sentence and divert someone like him into the health service where he might be better helped. It seems to me you might have to help agitate on his behalf with his lawyer. Remember many lawyers haven't the requisite expertise of mental health and forensic psychiatry so its also important to ensure you are with a firm with experience in this area.
Question 4
From CornishJazz:
I only caught the end of your programme so I may have missed some valuable points made earlier. I was struck, however, by the strange attempt to link mental illness with race and colour. I believe it is much more to do with coming into contact with a different culture and also in many cases linked to use of marijuana.
Dr Kwame McKenzie:
The rate of serious mental illness is four times lower for black people in Jamaica than in Brixton. Cannabis is unlikely to explain the increased rate of illness in people of Caribbean origin in the UK. If the increased rates were just due to coming into contact with another culture, then we'd expect increased rates in all ethnic minorities across the world. We do not find that.
Paul Grey:
I've never smoked a cigarette in my life so there's no basis for your assumption.
Question 5
From Rory Sheehan:
Why should this debate limited to people of Afro-Caribbean descent? Are there not other ethnic minority groups that are equally being failed by the mental health services in this country?
NB this is not only a criticism of this programme but of the wider field of transcultural psychiatry in general.
Dr Raj Persaud:
This is a good question. It seems different ethnic minorities are effected in contrasting ways by the experience of migration. For example there is now some good evidence that women from South Asia living in the UK experience particularly high rates of suicide and similar behaviour. The issue with African-Caribbeans is of particular interest at the moment because of the possible particular link with schizophrenia, which is regarded as the most serious non-fatal illness by some doctors. Many doctors are intrigued by the supposed high rates of schizophrenia in this community because then studying this group holds out the possibility of helping us better understand the cause of this disorder. We welcome your comments and will look at other groups with regard to mental health in the future.
Question 6
From Clare Dimyon:
A teacher friend was so shocked recently by the tratment of a black woman by her psychologist that she intervened, gently ushering her out of the door and seeing her on her way.
Teacher/Patient returns to room with psychologist saying "weren't you afraid?"
Her response was "what of?"
"A black woman?"
Should this patient have any confidence in the psychologist?
Paul Grey:
Many people have pre-judged black people before knowing the true facts. This may be one of those instances. Often these prejudices occur due to negative media coverage and it is unfounded as many black people actually suffer in silence. Maybe this person's training was out-of-date. The importance of professional staff's understanding of different cultures is paramount for their professional development.
Question 7
From Micheál Ó Ruairc:
I feel that it would be very useful to make a similar, comparative programme on the mental health of Irish people in Britain - an often 'invisible' ethnic minority but one which research has shown to be hugely overrepresented in the population of people diagnosed as having serious mental health disorders.
This might help us to better understand the complexities of how and why mental health problems are more manifest in certain communities and thereby arrive at better strategies for combating institutionalised racism within mental health services.
Dr Kwame McKenzie:
Down the road from you at the Royal Free and University College Medical School they are currently researching the mental health of Irish people living in the UK. The research will be published soon so I'm limited in what I can say about the results. I agree with you that it's well over-due.
Question 8
From Neil Swallow:
Is the situation In Holland where there is a significant number of afro-caribbeans the same as in the UK?
Dr Kwame McKenzie:
Yes, there has been work by Professors Seltem and Wellig looking at the rates of serious mental illness in this Caribbean migrants to the Netherlands. They show high rates of serious mental illness - again no one has come up with a reason - but no one in Holland has looked at social stress or racism as possible causes.
Question 9
From Alistair MacDonald:
Dear Dr Persaud - it's an established fact that a limited amount of sunlight can affect peoples moods/mental health. Is it possible that someone who's roots/origins are in a country where there's more sunlight than the UK, might therefore be susceptible to this and has any research been done?
Dr Raj Persaud:
Thanks for your email. It’s a very good thought and a few studies have been published on this.
There is no definitive guide yet but it is interesting to note that rates of Seasonal Affective Disorder do not seem to be dramatically higher in very northern countries like Iceland. It could be that over the centuries a population genetically adapts so that those who can't cope in that particular climate don't reproduce so much. This would mean that if you travel in the modern world and move to a country with a dramatically different climate to where generations of your forebears lived this could have an impact.
Remember that around 10% of the population in the UK suffer from clinically recognisable SAD or light starvation at winter, which can be effectively remedied by high intensity light which you can get from comercially available lightboxes. You can get the same effect much cheaper from an hours walk outdoors even on a cloudy winters day, every day.
It could be that those from sunnier climes need to pay particular attention to getting more light in winter - but its probably the cold that puts them off going outside as much.
Unlike vitamin D deficiency which occurs because darker skinned people don't absorb as much light in colder climates, the light starvation that causes winter depression or SAD occurs because of lack of light getting in through the eyes. So its important to look up periodically at the sky (but not directly at the sun) in winter.
Question 10
From Dave:
Why is there absolutely no suggestion that the black community bears some responsibilty for this situation, eg. for single parenting, drug use. Why must it be solely and completely the fault of "everybody else". Also, it is completely unbalanced and uninformative to give no indication of the behaviour your example patient was showing for him to be sectioned so often.
Paul Grey:
Part of my recovery was indeed taking charge of my own actions and my own life. I can't comment about the drug use because, as I said before, I've never taken drugs. It was my family who intervened many times to get me help and indeed to take care of me. In fact, one of the reasons why there's an increase in mental health problems in the black community is because the older generation, the parent-generation, are dying or going back home.
Dr Kwame McKenzie:
You may be interested to know that new research has shown increased rates of serious mental illness in people of Indian origin in the UK. It's difficult to put this down to single parenting or drug use or anything else to do with their culture.
Question 11
From Margaret Jessop:
Does the royal college realise that far too many service users can relate similar negative experiences of 'treatment' to those outlined by black users, whatever their ethnic origin and have a similar distrust and feeling of being treated without respect?
Dr Raj Persaud:
Dear Margaret,
I think you will have heard Dr Mike Shooter the President of the Royal College of Psychiatrists acknowledge on our special edition of All in the Mind, that there are problems in the way psychiatrists operate. I might perhaps defensively point out that as a psychiatrist myself working in the NHS many of my colleagues are working in a very stressful and unsupportive environment. I would argue the debate needs to be widened to the way the NHS works not just doctors or psychiatrists.
Question 12
From Carole Lovett:
Do you feel the increasing amount of user led research should play a greater role in the service commissioners decisions of funding of projects and services? The value of user research is classed as of the lowest credance in the 5 point scale of influence in the response at both government and local commissioning level, with random controlled tests (most commonly associated with drug testing) being of the greatest value.
Dr Kwame McKenzie:
I think that the UK is leading Europe in user involvement but there is a long way to go. I think that relevant user led research should have a prominent role in new service development but I think that it would be useful if there were better partnerships and equal partnerships between users and academics so that both types of research are focussed on meaningful questions that will make things better for people who use the services.
Question 13
From Peter Williams:
How could the programme ignore two obvious possible factors in the high
incidence of mental illness in Black people:
genetic differences
cultural differences
We should not automatically blame 'institutional racism' without considering
the other possible causes of a statistical trend.
Dr Kwame McKenzie:
People of Caribbean origin in Jamaica have the same genetic make up as people of Caribbean origin in the UK. But they have four times less serious mental illness in Jamaica. Genetic make up does not explain the high rates of illness in the UK. It would be interesting to know what aspects of culture are different in black people in the UK compared with Jamaica, Barbados, and Trinidad that you think could account for the increased rates here.
Question 14
From Rosealine Allen:
I was diagnosed as paranoid schizophrenic in 1993. For a long time I was non-compliant with the medication because i didn't believe I was ill. I now take 2 mg of Respiredone tablets twice daily religiously. What is the likelyhood of my ever being well again and not having to take medication. I am black British, my parents being of african caribbean origin.
Dr Raj Persaud:
Dear Rosealine,
I think there is a very good possibility that you will come off the medication in the future. However there are a couple of key factors which will help this. Firstly it is vital that you and those close to you can identify reliably the very earliest signs of the onset or relapse of the illness. This might be something as subtle as mild sleep disturbance. It is vital to restart the medication rapidly at the arrival of this kind of sign - even before you get an appointment to see your doctor again. You should probably be continued to be monitored after the medication has stopped. The medication should be stopped around six months to a year after the last appearance of any symptoms. With the correct management there is no evidence that your background should influence the outcome. It is vital incidentally that you absolutely steer clear of any recreational drugs, particularly cannabis - I am not suggesting you partake of any of these just pointing out the risks for other viewers of this email as well.
Question 15
From Michael Elvin:
How many bandwagon jumpers are taking advantage of the plight of vulnerable black people to create their own little empires and, consquently , denying black people the appropriate services to meet their particular needs, satisfying their own personal egos and self satisfaction?
Paul Grey:
There are a lot of power games that do go on. And a lot of musical chairs as well: things don't seem to change because new departments are set up but it's the same old faces that you see there. The reality of improvement is where people feel an improvement on the ground, an improvement in their lives. I'm not too interested in equal opportunities, but access to opportunities: economic, political, social.
Question 16
From Lucette:
What do think about the fact that french people are the first european consumers of medication against depression? And what do you think about the abusive consumption of these medications?
Dr Raj Persaud:
Dear Lucette,
I think that there is a huge controversy about exactly what is the prevalence of depression in the population at large and so its difficult to know whether depression is over-diagnosed or under-diagnosed. Remember there is no blood test for depression so the diagnosis is always going to be a bit of a clinical art. It is interesting to note that women in general supposedly have two to three times the rate of depression as men but men have two to three times the rate of alcohol dependency. Is it possible the men self-medicate their depression down the pub but women responsibly go to the doctor instead? My point is depression can also manifest itself in a variety of ways - sometimes hostility, aggression, addictions and even eating disorders.
Another interesting paradox to throw at you is that national happiness rates do not follow suicide rates - some supposedly happy countries in terms of measurement of the population also have high suicide rates. Note that the UK scores higher than France in terms of happiness and also suicide.
Question 17
From Rosemary Moore:
What was said in the programme equally applies to the white population. I am white middle class woman from an affluent part of the country - I look after two people who are caught up in the mental health system and I have been involved for over 30 years.
The comments about early death, obesity and other health problems resulting from medication are all prevalent across the board, as is the difficulty in accessing the most basic requirements from the services and welfare system.
Quite apart from the medication issue, I was particularly struck by Paul Grey's perceptive comments about the untherapeutic "ward rounds" and therapy generally that is provided.
Paul Grey:
Rosemary, I agree with you. I find that a service which lacks love can only articulate dim walls and untherapeutic practices. The greatest stimulus for the mind is love.
Dr Kwame McKenzie:
Of course you're right. We have a long way to go in psychiatry before we offer balanced and humane treatment. In the 14 years I have been in psychiatry things have improved, but it is very slow. The problems faced by people from ethnic minorities is that many of the inherent difficulties in the system are magnified so there is a double whammy of discrimination due to having a mental health problem and being from an ethnic minority.
Question 18
From Anon:
I am a survivor of the metal health system and can identify with Paul; I too have had to make my life a success myself and with little support from the system. However I found that cognative therapy changed my life (I took part in a pilot in Manchester) and this inspired me to become a substance misuse worker. Unfortunately the issues of racism in the field of work that I am in are very similar to those described in your programme. Do you think cognative therapy is a positive way forward to treating mental illness experienced in the black community? and in the community as a whole?
Dr Raj Persaud:
Dear Anon,
I think that the development of the use of CBT (cognitive behavioural therapy) in psychosis and schizophrenia is very interesting. You may find the programme we did in this series where we looked at the use of virtual reality and cbt in the treatment and assessment of psychosis particularly interesting. The big advantage of CBT is that it can be done by yourself without the need of a therapist - if I may take the risk of blowing my own trumpet - my own book 'Staying Sane - how to make your mind work for you' published by Bantam Press at Β£7.99 might be of help as it's all about self-help approaches to mental health including the latest CBT approaches.
Question 19
From Bhavesh Hindocha:
I was struck by the uncertain tone of Kamlesh Patel in explaining the Government's new strategy - we've had too many initiatives! Would the panel concur that the answers to providing a better system of mental health are already being practised in projects around the country, but this best practice needs to be brought together, then rolled out nationally with appropriate resources?
Dr Kwame McKenzie:
I agree, the answers are there. The question is how to get them into wider practice. This is easier said than done because lots of people do not want to change. Some of the posturing that has gone on is to do with how you manage to get chief executives and PCTs to change and how you get the resources out of various government coffers. Unfortunately this is a complex game that is often difficult to fathom. To people on the ground this is their lives, but to others this is politics. Kamlesh is trying his best.
Paul Grey:
The strategy failed from the outset. The lack of consultation with service users, again a lack of understanding with what's really happening on the ground, many of the black service providers don't even know about the document. It seems to me when Martin Luther King wanted to understand the needs of a community, he went to live among the community. The smell of urine in housing estates is a reality - it meant that he marched with boldness, his heart fuelled with passion and a dream.
Question 20
From Sandy and Jess:
Is there any research into the numbers of young black women who have a diagnosed severe mental health problem and whose children are taken into care? What support is there outside of London for women who have experienced the above?
Dr Kwame McKenzie:
Unfortunately young black women who've had their children taken into care are more likely to suffer from serious mental illness and sadly so are their children. This is a national disgrace on which there has been very little research and there is very little support for people in this situation. Outside London there is precious little support unless you are the Liverpool or Birmingham areas, where there are projects trying to set up some culturally-specific services.
Question 21
From Kate:
A member of my immediate family has in the past year experienced the mental health service, but little has been done to further his treatment and care. We are slowy seeing a decline in his progress and I am worried that things will go from bad to worse. I am 17 yrs old and do my best to understand everything. I feel very much central to his recovery as he relies on me to an extent and values what I say. What can I say to motivate him and help him?
Dr Raj Persaud:
Dear Kate,
It's absolutely vital that at this early stage your relative is encouraged to do something about their situation before it worsens. Start not from the standpoint of illness but what do they want to do with their lives - what are their long and short term goals? What do they really enjoy? Encourage them to participate in these and then you can work on those things that are preventing them achieving what they want, which is then that they are more likely to see the point of doing something about their situation. Remember you can also go to their GP and encourage a referral to the mental health services - it sounds as though a visit to your home from a community psychiatric nurse might be of benefit - you can always ask the GP or the mental health services he had been involved in to help with this. In extremis a letter to the relevant GP or the past Consultant where you map out your concerns is likely to achieve more as people in the NHS are worried about things in writing and are less likely to ignore a letter.
Question 22
From Della:
Surely the main element of difference between the experience of black and white patients is to be found in the level of support that an individual's family and immediate community actually afford and extend to them in an effort to gain their release and a return to health. Also, on the racial question again, particularly institutional racism, many if not most nurses in some London Psychiatric institutions are black. How does this impact on the accusation of discrimminatory and/or institutionally discriminatiry practice?
Paul Grey:
That's why when I was speaking on the programme my comment was that I wasn't too interested in institutional racism, it was individuals who didn't understand their self-worth operating in an evil manner. Thank God we have strong black families holding everything together!
Dr Kwame McKenzie:
There may be lots of black nurses but there are not very many black psychiatrists or managers. The way that diagnosis is made is built on a model set up by maily white psychiatrists and the way that services are set up are built on models set up in a white European tradition. It's not very surprising that people with a different world view find the services difficult to feel comfortable with. Even if you have black nurses, if they're running a white European system, they can be just as discriminatory. Institutional racism is not simply about the colour of the skin of the perpetrator. It is about how a system of care produces different outcomes for different people. It is impossible to see the high rates of black people brought into hospital involuntarily for 30 years now with no initiative to sort it out and not say there is something wrong with what we're doing.
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