Women of colour are facing racism and discrimination in accessing mental health support
In the spring of 2017, the Scottish Government launched its ten-year mental health strategy with a vision to eliminate discrimination and stigma, where the right treatment and support at the right time would be available for all.
This commitment to meaningful investment in trauma-informed, rights-based, person-centred approaches to mental health recovery created a whirl of optimism across the mental health community.
But based on interviews I’ve carried out over the last five months with professionals working across the NHS and third sector, in both frontline, managerial, and strategic roles across Scotland, I sense a clear disconnect between mental health workers knowing what a trauma-informed approach is, and having the skills, time and resources to meet people’s needs.
Participants spoke to me of concerns in both hospital and community settings of workers not following trauma-inducing protocol because of the lack of embedded trauma-informed practice.
Similarly, patients shared common experiences of being treated with hostility, with minimum regard, or with a lack of awareness of how to respond to what they viewed as being important to their lived experience of trauma and mental ill health.
Feelings of helplessness and frustration were commonplace on both sides of the services. Professionals that want to make a difference said they were stymied by medicalised and alienating bureaucratic systems and unnecessarily complex processes. People using services spoke to me about not being meaningfully included in their treatment and care decisions and not being able to access crisis support and/or therapeutic interventions because they don’t meet rigid clinical criteria, or they simply weren’t available in their area.
This is disappointing because Scotland is recognised as a leader in mental health recovery and has long advocated for the expertise of lived experience to be included in the design and delivery of mental health services.
Healthcare Improvement Scotland, Public Health Scotland and the National Care Service all agreed on the need to collaborate with communities for healthcare solutions, ensuring people’s rights, choices and participation are centred in their mental health treatment and care.
However, to put it bluntly, we have a mental health system which remains dominated by the medical model, where clinical diagnosis and medication are viewed as the main route to better mental health. This isn’t a critique of the value of a diagnosis and applicable treatment for some people; it’s the reality that people across Scotland are being diagnosed via assessment processes lacking a rights-based, person-centred, trauma-informed approach.
Where assessment and treatment planning should be a careful and collaborative process, people have told me they have been rushed through assessment with little regard for their psychological safety and wellbeing.
Informed of diagnosis in a brief appointment, offered no aftercare, and when prescribed medication, the approach lacks consultation. I heard stories about service users not being informed of side effects or offered support on how to manage them.
Overall, there was a sense that there is little or no communication around what a diagnosis might mean for an individual or for what they saw as being important and required for their mental health and wellbeing.
Mental health supported living services are funded to help people live a meaningful quality of life but there is no doubt that many of them are hampered by time and task contracts. Administering medication in fifteen-minute appointments leaves little time to build a meaningful connection with the person involved and support what is important to them and their recovery and wellbeing.
Often in circumstances where people are beset with side effects and believe they are on the wrong medication and wish to have a review, there is no timely and effective process to follow.
The policy is there to assert people’s right to refuse medication, yet people I spoke to said it was regularly viewed as non-compliance due to a lack of safety-orientated training and resourcing in services. People are frequently informed they have no choice but to take the medication as there is no reliable alternative route to follow.
Scotland’s treatment and care system maintains a primary focus on managing symptoms without consistent time, space and sufficient resources dedicated to co-creating safe spaces alongside the expertise of lived experience.
Across clinical and social care services there is an ingrained tendency to view people through the lens of referral information and diagnosis rather than understand and respond to a person’s individual perspective and experience of their own mental ill health. Building a trusted rapport and being alongside people exploring what their experience of mental ill health and recovery means requires a genuine understanding and commitment to a personal outcome approach.
Josephine Beavitt, who is based on Skye, spoke of the crisis-led approach with a lack of access to consistent or joined-up services. People contributing to the research from across localities in the Highlands and Islands close to where Josephine is based spoke of a necessity to please GPs and the skeleton staff of mental health workers out of fear of being denied access to services. (Photo: Nikki Kilburn)
We know quantitative data is concerned with numbers. It tallies up how many people have been discharged from the hospital, are receiving community resources, and no longer require services. Crude and simplistic as it may sound, it is a goal-orientated progression model focused on moving people from illness to wellness. An outcome-focused approach would capture the difference a person feels from the treatment and care they receive for their mental health.
It seems to me that part of the problem is the meaning of recovery has become contaminated with the notion that what has been lost through illness can be recovered, implying wellness was a state from which someone has become unwell, and they can get back to that place with the right intervention.
Not to be conflated with the reasons why people may need lifelong intervention, recovery is a journey of experience, not a series of accomplishments with an endpoint. Unfortunately, many of our research and data systems and applicable thinking processes still reflect the what over the why.
We know a holistic approach to mental health recovery works, yet we are still stuck in a place where people are being treated through a disempowering psychiatric framework and are at risk of misdiagnosis, poor treatment, stigmatisation and discrimination.
The congruent theme across interviews for this feature was that power consistently remains in the system and attempts to balance the power are too often met with resistance and a lack of knowledge of how to genuinely work with outcomes approaches. There is also a lack of top-down consistent investment in the expertise of lived experience.
The inclusion of lived experience in the development of policy, service design, and delivery is, I believe, patchy across the sector. There is some great work alongside too many examples of a poor attempt to work in consultation and alongside the expertise of lived experience.
A standard appears to be that people and communities are involved only once the decisions have been made. Often by a reference group with limited influence. I have seen that when it works well, lived experience is valued and included at the inception of design. A balance of lived and learned experience is yet to be fully realised.
Some of the individuals who shared their knowledge and expertise with me for this feature are from marginalised communities. They spoke of their experience of racism and discrimination within the mental health system. They described this as a Scotland-wide problem where English as a first language and being white and middle class informs the quality of care received.
As a result, accessing services during Covid via phone calls was seen as being considerably better for some, who said being well-spoken and not being visible resulted in more constructive outcomes and helpful responses.
We already know there is a need for specialised services to meet the needs of communities and specific lived experiences. However, we also need to be aware of the risk of communities becoming siloed and further marginalised.
Not all BPoC (black people and people of colour) are going to access community-specific services. There is not just a need for mental health professionals to attend anti-racism training. It is a national issue requiring a national framework and consequent strategy and learning resources.
Several professionals in leadership roles spoke of a universal and preventative approach to mental health and wellbeing, where embedded in communities are accessible walk-in services for all. Normalising mental health as something we all experience and having better population-wide access to information and support in community spaces could potentially save millions.
Nina Abeysuriya, mental health service manager at Intercultural Youth Scotland, works alongside young black people and people of colour. Part of her work is focused on raising awareness of the lack of early intervention and racialised trauma-informed services. Given the lack of nonclinical services for young people, she said young black people and people of colour are aware their condition needs to be serious before they can get access to help. (Photo: Nikki Kilburn)
Mental health support should not just be synonymous with crisis and psychiatric services. There should be a straightforward intervention connecting with the person on what is important to them and their needs, with interventions that can prevent things from deteriorating.
At the end of the day, it isn’t rocket science: we all need a safe space with a person-centred response to help to navigate our mental health needs. People should be getting the same service regardless of background and life circumstances.
If we are to meet the expectations of the mental health strategy over the remaining five years, I believe it requires a seismic shift in how things are currently operating, with accountable collaboration with communities and people with lived experience.
Nikki Kilburn works in mental health practice development and is the creative director of True and Woke, a media project focused on centring the experience of marginalised communities. She is taking part in the Pass the Mic initiative, which seeks to promote more women of colour commentators in the media.