Narinder Bansal has worked as an academic in the field of Ethnicity and Health for 15 years. She is an honorary Research Fellow in Mental Health at the University of Bristol and Consultant on the Ethnicity and Mental Health Improvement Project (https://emhip.co.uk/).
Alice Malpass has a background in anthropology, has worked in primary care mental health since 2007 and is currently an honorary Senior Research Fellow in Academic Primary Care at the University of Bristol.
Carolyn Chew-Graham has worked as a GP in Manchester for over 30 years. She is Professor of General Practice Research at Keele University focusing her research on management of distress and mental health problems in primary care.
Ethnic inequities in mental health care have been consistently recorded over the past 50 years.1,2 Research continues to show that people from ethnic minority groups are more likely to come into mental health care via crisis pathways than through primary care in the UK,2 a pattern that is mirrored across other multi-ethnic nations in the global north.2,3
Research continues to show that people from ethnic minority groups are more likely to come into mental health care via crisis pathways than through primary care in the UK
In our recent study4 we found that fears and concerns about being misunderstood by their doctor underlie peoples’ narratives about barriers to access across ethnic minority groups. These concerns relate to the presence of low cultural knowledge and negative racial stereotypes within services and the short duration of primary care consultations. Ten-minute encounters are perceived to be inadequate for conversations about emotional distress, especially if you have to explain your culture and religion to the doctor first. This difficulty is magnified by the move to remote consulting and a more transactional style of consulting during the COVID-19 pandemic.5 In our study,4 participants described how experiences of poor listening and cultural misunderstandings resulted in avoidance of, and disengagement from, services. For some this meant that crisis pathways and police involvement might be the only available pathway to mental health services.
So what role can a GP play in tackling this seemingly intractable problem in the context of providing equitable person-centred care in an increasingly resource-constrained health system?
Illness narratives and cultural/social models of illness
What we need to hold in mind is that there are multiple overlapping and intersecting stories.
There is the story of the patient seeking to make sense of their life and troubles through illness narratives. These narratives are shaped by cultural and social models of illness.6 Another is the story of mental health institutions, and how they have historically intersected with ethnic minority communities. Both of these stories have complex histories where the narrative collision serves to shape and perpetuate themes within each other. Negative experiences of service use are held, remembered, and retold across generations and communities. Within services, negative stories of ethnic minority communities underlie stereotypes and relate to so-called primitive, repressed, deviant, aggressive, and dangerous individuals.7-9 Finally, there are the stories of migration and migrants shaped by policy and public concerns about legal entitlement and the media response to these. The burden on the practitioner is to understand how these stories collide within the clinical encounter and shape the consultation.
Underneath the fear and concern that some people have in presenting their distress to a healthcare professional is the desire to be seen and heard without judgement or bias; the need for human connection and understanding. For patients who have an established therapeutic relationship with their GP, primary care can indeed be a lifesaver. It is the first step in establishing trust and breaking the cycle of fear in relation to formal service use.8 GPs have an important role in starting the healing journey, not just for the individual patient, but for entire communities. Therapeutic clinical encounters can create positive stories of service engagement that can be transmitted across generations through the threads of close-knit and interdependent families and ethnic minority communities.
…decolonisation of mental healthcare, cultural competence, and anti-racist practice starts in the clinical encounter.
In this sense, we posit that decolonisation of mental healthcare, cultural competence, and anti-racist practice starts in the clinical encounter. A trusting relationship based on seeing, hearing, and understanding the patient without judgement or bias can transcend colour lines. This, however, requires practitioners to re-examine the lens through which they view their patients. In psychotherapy, this is achieved through regular reflection and supervision. GPs do not generally have supervision. Ten-minutes may not seem like a long time to establish a therapeutic alliance, but this can be built over multiple encounters and we can make every minute count by turning down the noise created by bias and expectation.
By being sensitive to how experiences of poor listening and relating can replicate and trigger wider experiences of marginalisation, we can sit with the patient and invite the whole person in with curiosity and respect. By doing this we leave the door open for them to return exactly how they are.10
References
- Cooper C, Spiers N, Livingston G, et al. Ethnic inequalities in the use of health services for common mental disorders in England. Social Psychiatry and Psychiatric Epidemiology 2013; 48(5): 685-692.
- Barnett P, Mackay E, Matthews H, et al. Ethnic variations in compulsory detention under the Mental Health Act: a systematic review and meta-analysis of international data. Lancet Psychiatry 2019; 6(4):305-317.
- Chiu M, Amartey A, Wang X, Kurdyak P. Ethnic Differences in Mental Health Status and Service Utilization: A Population-Based Study in Ontario, Canada. Can J Psychiatry 2018; 63(7): 481-491.
- Bansal N, Malpass A, Cohen R, et al. Understanding ethnic inequities in pathways to mental health services: A meta-ethnography of perceptions and experiences of people from ethnic minority groups. National Institute for Health (NIHR) Research for Patient Benefit (RfPB) Ref. NIHR201058. https://bnssgccg.nhs.uk/about-us/what-we-do/research-and-evidence/our-research-portfolio/funded-plain-english-summaries/understanding-ethnic-inequities/ (accessed 24 Mar 2022).
- Turner A, Morris R, Rakhra D, et al. Unintended consequences of online consultations: a qualitative study in UK primary care. Br J Gen Pract 2022; DOI:https://doi.org/10.3399/BJGP.2021.0426
- Kleinman A. The Illness Narratives. Oxford: Oxford University Press, 1988.
- Burr J. Cultural stereotypes of women from South Asian communities: mental health care professionals’ explanations for patterns of suicide and depression. Soc Sci Med 2002; 55(5): 835-845.
- Keating F, Robertson D, McCulloch A, Francis E. Breaking the circles of fear: A review of the relationship between mental health services and African and Caribbean communities. London: The Sainsbury Centre for Mental Health, 2002. https://www.centreformentalhealth.org.uk/sites/default/files/breaking_the_circles_of_fear.pdf (accessed 24 Mar 2022).
- Faulkner A. Ethnic inequalities in mental health: Promoting lasting positive change: A consultation with black and minority ethnic mental health service users. Lankelly Chase by NSUN (the National Survivor User Network), 2014. https://www.nsun.org.uk/wp-content/uploads/2021/05/Ethnic_Inequalities_in_Mental_Health_Report_February_2014.pdf (accessed 24 Mar 2022).
- Cocksedge S, Greenfield R, Nugent GK, Chew-Graham C. Holding relationships in primary care: a qualitative exploration of doctors’ and patients’ perceptions. Br J Gen Pract 2011; DOI:https://doi.org/10.3399/bjgp11X588457.
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