Services aimed at minority ethnic populations are all too often developed on the basis of conspicuous morbidity than on any real understanding of the diversity of ethnic minority communities and their wider health needs. For example, in England, while much has been written about ethnicity and psychiatric morbidity, the literature remains largely focused on African-Caribbeans and Asians, while the needs of the Irish, who comprise the largest ethnic community by migration in many parts of the UK are seldom explicitly addressed despite evidence of high rates of suicide and unexplained death many times in excess of the indigenous population.⁽¹⁾ In addition, the large numbers of asylum seekers and refugees who move around the world, brings an increased need for culturally sensitive services. But very few models exist for developing these. The principles of good practice indicate that the start has to be a clear knowledge of the population that will be accessing services and an appreciation of the complicating factors of social disadvantage, material deprivation, and poverty.

There is no doubt that social disadvantage and racial prejudice whether real or perceived are pivotal in determining not only the mental health of minority populations but also the pathways individuals and their families use in seeking help for ill health. Delays in help-seeking can also be due to the stigma of mental illness and to sufferers’ fears that they will be misunderstood and mistreated because of differences in culture, language, and racist attitudes within the services. These factors may be more apparent in older individuals and those who were born outside the country who may not be aware of various options available to them. Studies over the past 30 years or more in Britain, the Netherlands, the United States, Canada, and Australia have shown that minority groups have lower access to mental health services, are less likely to receive care, and when they do this is more likely to be of a lower quality. Black people in the UK and the United States are more likely than white people to be compulsorily detained in hospital, to be screened for drug abuse, to receive higher doses of medication and physical rather than psychological therapies. They are over-represented compared with their numbers in the general population, whether in general wards, locked wards, secure units, court diversion schemes, special hospitals, or prisons.⁽²⁾

Some of these problems can be attributed to a lack of understanding on the part of mental health practitioners of the cultural beliefs, values, and practices of minority groups with consequent shortcomings in assessment, diagnosis, and the provision of care. While language can be a major obstacle, for many people from minority ethnic groups who speak English the problem is of communication rather than language. The power dynamic that is always present in any clinical consultation is magnified and both patient and doctor will have predetermined expectations of how their interaction will turn out depending upon their experience of previous consultations. Problems in the interaction are likely to be interpreted as arrogance and racism on the one hand and indifference, wariness, or docility on the other. Thus, both missed diagnoses and misdiagnosis may result. A lack of recognition of the personal, social, and cultural problems which influence the presenting patterns of symptoms in different ethnic groups can contribute to the tendency of clinicians to make assumptions and listen out for stereotypical triggers which then prompt a particular therapeutic response. Such triggers include religious euphoria, use of Cannabis in African-Caribbeans, and the ‘fatalistic attitude’ attributed to Asian patients.

The past decade has seen an emerging consensus that the way forward lies in the development of fully integrated multicultural services with good working links with the local minority community rather than separate services. Such services would provide staff who can understand their client’s cultural background and the ways in which this influences the presentation of distress and disorder. There would be closer working links with religious leaders and healers of local ethnic minority communities, female-only areas on wards, and a greater involvement and support of the family in understanding the problems and developing solutions.

In North America,^{(3, 4)} Britain,⁽⁵⁾ and Australia⁽⁶⁾ there has been a significant ‘top-down’ pressure to shift health care organizations in this direction and several large-scale programmes such as the European 9-country ‘Migrant-Friendly Hospitals’ initiative⁽⁷⁾ have been reported. Although differing in detail, all these programmes share common elements. These principles are outlined in Table 7.10.3.1 setting out the main conclusions in a ‘bottom-up’ approach in order to emphasize the importance of changes in the attitudes, knowledge, and skills of front-line managerial and clinical staff.