Journal of Community & Applied Social Psychology, Vol. 6 , 335-340 (1996)

Developing Black' Mental Health Provision: Challenging Inequalities in Partnership

SHARON JE"INGS* Training and Consultancy Services, I19 Beverstone Road, Thornton Heath, Surrey CR7 7LR, UK

ABSTRACT

This article describes and comments upon the process of developing the Sanctuary project in London, a project that will provide two community-based crisis support services for African and African-Caribbean women and men in mental crisis and distress. This initiative is informed by the extensive research documenting the ways in which mainstream, mental health services fail Black people, and by evidence suggesting that innovations in service provision for Black people are often vulnerable and limited in their impact. In an effort to avoid replicating these problems, considerable emphasis has been given to developing the project in partnership with the main stakeholders-in this instance statutory and Black voluntary sector agencies as well as Black users, carers and community members. Within this context, issues relating to inequalities can be proactively addressed, thereby reducing the risk that they undermine the effectiveness of service provision at a later stage. However, working in partnership can also hinder or delay service developments if discussions between stakeholders become protracted or conflicts unresolved. The author draws on experience gained from this project to identify the potential as well as the difficulties of using a partnership approach to developing effective Black mental health provision. The author's role in the development of these projects has been as representative of one of the partners, the King's Fund Centre for Development.

Key wor& race; mental health; service development; partnership; Black user and carer collaboration.

INTRODUCTION

This article focuses on the process of developing the London-based 'Sanctuary' community mental health projects for Black people. It describes attempts to avoid replicating inequalities commonly found in mental health services for Black people. These inequalities and their effects on the iives and experiences of Black people are now well documented in the research literature (see, for example, NHS Mental Health Task Force, 1994; Fernando, 1988, 1995; Wilson, 1993; Watters, this issue; Ferguson 1992, Harris 1994, Littlewood 1989, Sashidharan & Francis 1992).

'The term 'Black' as used in this article refers to people of African and African-Caribbean origin. The mental health projects discussed here are aiming to provide a service for this group of people. However, it is recognized that the type of inequalities discussed here are shared by other racial and cultural groups. By emphasizing one group, this is not meant to deny the experiences of others. *Sharon Jennings was formerly a Development Consultant in Race and Mental Health at the King's Fund Centre for Development, London, UK.

CCC 1052-9284/96/050335-06 01996 by John Wiley & Sons, Ltd.

336 S. Jennings

ESTABLISHING THE NEED FOR PARTNERSHIP

The impetus for the Sanctuary projects came from the King’s Fund Centre for Development2 in response to unequivocal evidence about the ways in which Black people are consistently failed by mental health services. It was decided to develop a small number of community services that would provide a valued alternative to the predominately hospital-based provision Black people usually receive, rather than to attempt to change existing mental health services (Christie, 1993).

Our approach to this project was informed by an awareness of some of the pitfalls in developing Black mental health services. For example, it is very common within the voluntary sector for Black organizations to be funded in ways that make it difficult for them to become established. Even apparently viable services are at risk of becoming marginalized and eventually viewed, particularly by funders, as less of a priority. On the other hand, those Black organizations that have close links with statutory agencies can find their decision-making compromised, or their ability to survive as independent agencies put at risk.

In addition to addressing conflict embedded in the development and funding of Black services, it was essential to avoid replicating the inequalities and cultural insensitivity that are evident in mainstream mental health services. Attempting to eliminate or minimize inequalities once a service is in operation is difficult, and we were concerned to prevent their occurrence from the beginning.

Working in partnership with a range of organizations and interest groups was identified as an important way of securing broad-based support for the Sanctuary project, and ensuring that it did not replicate the limitations commonly found within mainstream mental health services. Involving the statutory and Black voluntary sectors, Black users, Black carers and Black community members from the early planning stages until the service was operational would, it was thought, go some way to ensuring that the project would provide valued and viable alternatives to existing mental health provision. Two key districts were identified (Lambeth and Hackney) through a process involving selective tendering and networking, and the initial partners in both areas were health and social services (Christie, 1993).

PARTICIPATION AND PARTNERSHIP

The two main Sanctuary projects are now in their third year of development. Each project has a development worker funded for 2 years by the King’s Fund, and is being developed by committees made up of the following partners: health and social services providers and purchasers; Black voluntary sector managers and front-line workers; Black users and carers; Black community members; and a representative from the King’s Fund acting in an advisory capacity. Both committees meet regularly, to discuss and make decisions on the varying developmental aspects of the project. This process is facilitated by inputs and guidance from the development worker. (Hackney African-Caribbean Crisis Sanctuary (1995); IPAMO- Alternative to Hospital (1995)).

’The King’s Fund Centre of Development is an independent health organization, working to develop and support innovation in health and social care.

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Although developing these projects in partnership was seen as essential to the development of relevant and secure mental health services for Black people, working in partnership has not always been easy. This has much to do with the controversial nature of the projects, the conflicting expectations of individuals, and the power inequalities in the relations between the different partners, e.g. between the statutory and the Black voluntary sectors.

In the course of developing the projects several issues have arisen that have needed clarifying, addressing or resolving outright in order to further the development of the projects. Failure to do so would have severely affected the outcomes to these initiatives. Some of these issues and the steps taken to resolve them are described below.

Establishing a shared vision The Sanctuary projects were initiated to develop sensitive and effective mental health services for Black people; more specifically:

0 To provide a community-based, crisis support service for African-Caribbean

To offer a 24-hour 7-day-per-week service. 0 To provide a service that the Black community had faith in and would use. 0 For the projects to become independent Black-managed agencies.

Once the partnerships had been established, it became necessary to revisit these aims. It was apparent that each of the partners had a tendency to see the intended development from their own perspective. For example, health officials who are familiar with developing hospitals and acute services saw the new development in these terms. It was the same for the other partners. This process was one of negotiation and compromise, as some of the individual ‘visions’ were in conflict with each other. This revisiting and re-affirming occurred several times during the life of these partnerships. The once-agreed-upon concepts got lost or forgotten in the midst of the nitty-gritty developmental tasks, such as securing funding.

With regard to the race focus of these projects, one of the areas that needed extensive work was the shared understanding of the value of having a service run by Black people, for Black people. Though explicit in the initial aims, this was and remains in some respects a contentious issue. Different partners have different views on this, and, as some may expect, it does not fall neatly down racial lines, i.e. all the Black partners do not share the same view. There is ongoing work within the partnerships in coming to an agreement of what we mean by a Black independent service for Black people.

women and men.

Power, trust and respect Power has been a central theme. Power in this context is usually defined by status, resources, skills and knowledge. Each of the partners brought these elements from their different origins and these could be seen collectively as the strengths of the partnership. However, it can prove difficult to value an attribute in another when he/ she is coming from a different perspective. For instance, how does a senior manager in social services understand and value the status, skills and resources of a Black carer?

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How, indeed, can the partnership group meld its strengths and minimize the areas of weakness? These are some of the dilemmas that continue to face the partnerships. Problems in dealing with this has led, at times, to feelings of distrust and lack of respect. This, in turn, has been manifested in many ways, including veiled and open conflicts, low attendance at committee meetings, decisions made at meetings being overturned outside of meetings and low morale.

Involving Black users and carers An essential element of the development of these projects was the continued and consistent involvement of Black users, carers and members of the Black community. However, this has not proved a very straightforward proposition. A number of difficulties have arisen. Firstly, there was a lack of clarity about the level of involvement expected of Black users and carers. Equally unclear was the level or type of involvement that Black users and carers wished to have. Was it sufficient that users and carers were consulted initially and their views obtained or was there a requirement that they become full members of the development committees, attending regular meetings and being part of the decision-making process in that way? Or were there other ways that would be both empowering to Black users and carers and facilitate the development process? Lack of clarity here has sometimes led to difficulties in engaging and sustaining Black user and carer involvement.

Equally, the process and structures involved in developing a mental health service, the long-winded meetings, full of technical jargon and baffling procedures enmeshed in mounds of paper, can be disempowering to Black users and carers. ‘Why does it take so long?’ is a common cry from Black users and carers, whose need is immediate and pressing.

Finally, a lack of Black mental health user-led networks in the areas where the Sanctuary projects are being developed meant that it was difficult to obtain the views of Black users directly. This meant that, for the most part, the views of Black users were voiced by mainly White user organizations, professionals or Black carers.

RESOLVING DIFFICULTIES

During the course of the partnerships, many strengths have evolved. These have included individual strengths as well as the combined strengths of the committees. Both have been invaluable in addressing, or at least minimizing, the impact of the above difficulties.

The following have been identified as important dimensions for any effective partnership attempting to develop Black mental health projects.

Clear terms of reference. This refers to the rules and roles of members of the partnerships. Each of the partners will have different ways of working and will have varying and often conflicting expectations of their role and the roles of others. To offset confusion or tension, certain areas need to be made explicit and these include: the basis for membership; the roles of different members; how decisions will be made; and how conflicts will be mediated. In formulating the partnership’s terms of reference, account needs to be taken of existing power imbalances. For example, as most partnerships are initiated by statutory bodies,

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their representatives will inevitably have areas of responsibility and accountability that are not shared by the other members, e.g. with regard to finance. The partnership will need to explore the effect this has (both positive and negative) and reflect this within the terms of reference, e.g. adopting a process of decision- making which requires the presence of all members when financial matters are to be decided.

0 An ability to be open and honest. Issues regarding race, power, conflict and disagreement need to be put fairly and squarely on the table. They need to be discussed openly without personal attack or justification.

0 Time. Partnerships need to give time to developing themselves as a working group, as well as to the main task of service development. For example, there needs to be time set aside for the group to assess how it is working, to recap on past achievements and chart the way ahead.

0 Creativity and resourcefulness. This has been particularly important in ensuring the participation of users and carers. Ways of involving users and carers-individually and collectively-have ranged from using the local radio station, organizing separate user and carer consultation events, publishing a newsletter, holding committee planning meetings at venues frequented by Black users and carers, as well as tapping into existing networks, such as local mental health user forums and patients’ councils. In addition to this, changing the shape and structure of meetings, choosing accessible venues and times, and agreeing a shared ‘language’ at meetings have all gone some way to improving the involvement of Black users and carers in these developments.

0 Flexibility. Effective partnership working requires clear thinking and the ability to negotiate and come to workable compromises. This does not mean that everything can be negotiated: there will be issues that can not be negotiated and it is important that these be made clear at the outset. Nonetheless, partnership working is seriously compromised when members, or the organizations or interests they represent, are consistently rigid in their attitudes or perspectives.

0 Commitment and enthusiasm. The process of developing a service can be long, difficult and challenging. Most of the partners will also have many other responsibilities needing their time and attention. Attention needs to be paid to sustaining the group’s enthusiasm and commitment to the development, even when the going is rough.

SUMMARY

The focus of this description and commentary has been the process of developing effective mental health services for Black people. It asserts that working in partnership can assist in redressing some of the inequalities, especially those that stem from marginalization of services, inapproriate funding patterns, insensitivity in service delivery, and lack of faith and ‘ownership’ by the Black community.

Partnership working between different organizations, individuals, disciplines and interests carries difficulties that are often rooted in social inequalities. Addressing these issues constructively is a key to building services on strong foundations. However, this requires partners to be open, honest, willing to trust, listen, assert, challenge and negotiate around some very sensitive issues, race being one of them.

340 S. Jennings

If we are committed to creating and changing the types of mental health services available for Black people, then the effects of racial and other social inequalities need to be on the agenda in the planning phase and throughout all stages of development.

REFERENCES

Christie, Y. (1993) ‘An effective model for consultation fo developing a mental health service

Ferguson, G. (1992) ‘Race and mental health‘, Community Psychiatric Nursing Journal, 12(6),

Fernando, S . (1988) Race. Culture and Psychiatry, Routledge, London. Fernando, S. (ed.) (1995) Mental Health in a Multi-ethnic Society, Routledge, London. Hackney African-Caribbean Crisis Sanctuary (1995) Uniting All the Partners in Community

Mental Health Cure: a Business Case, Community Psychiatric Research Unit, London. Harris, V. (1994) Review of the Report of the Inquiry into the Care of Treatment of Christopher

Clunis: a Black Perspective, Race Equality Unit, 5 Tavistock Place, London WClH 9SN. IPAMO-Alternative to Hospital (1995) Initial design brief, West Lambeth Community Care

Trust Planning Department. Jennings, S. (1996) Creating Solutions: Developing Alternatives in Black Mental Health, King’s

Fund, 11-13 Cavendish Square, London WlM OAN. Littlewood, R. and Lipsedge, M. (1989) Aliens and Alienists: Ethnic Minorities and Psychiatry,

Unwin Hyman, London. NHS Mental Health Task Force (1994). Black Mental Health-a Dialogue for Change,

Department of Health, London. Sashidharan, S . P. and Francis, E. (1992) ‘Epidemiology, Ethnicity and Schizophrenia’, in W.

Ahmed (ed.), Race and Health in Contemporary Britain, Open University Press, Milton Keynes.

for Black people’, unpublished dissertation.

11.

Wilson, M. (1993). Mental Health and Britain’s Black Communities, King’s Fund, London.

CONTACTS

IPAMO (formerly the Lambeth Sanctuary), c/o 332 Brixton Road, London SW9. 0171 738 6667

Hackney African-Caribbean Crisis Centre (formerly Hackney Sanctuary), c/o Kofi Sunu, KUSH Housing Association, 98 Stoke Newington High Street, London N16 7NY. 0171 275 7783

3Since this article was written, the development of the ‘Sanctuary’ projects has reached an advanced stage. For more information about the projects, please refer to Jennings (1996) and the ‘CONTACTS’ section above.