Racism on mental health wards impacts patient experiences of care, research shows

Racism in mental health care is perpetuated by a culture of silence, a new study has found.

The research, carried out by the University of Birmingham, University of Oxford and Queen Mary University of London, found that both staff and patients in in-patient facilities experience racism, resulting in a lack of psychological safety. The study is published in the British Medical Journal Mental Health

People from ethnic minority backgrounds (“racialised groups” in the study) are over-represented as patients in mental health services and among those detained under the Mental Health Act. They are also more likely to receive coercive care and medication rather than psychological support. There has been little academic research on this issue, however.

Using qualitative methods, the researchers scrutinised the deep experiences of 10 patients who reported racism in the EURIPIDES study of patient experiences in NHS mental health services.  There were 62 interviews in the EURIPIDES Study, and the 10 interviews selected for analysis made “explicit or implicit” references to race, racialisation or racial discrimination that were relevant to patient care or experience. For example, the authors say, they “addressed keywords or concepts like microaggressions, name calling, insults, attacks, exclusion, being refused service, bullying, harassment and hate crimes”.

The original EURIPIDES interviews were conducted with patients from four different geographically located NHS England mental health trusts between July and October 2017.

In interviews, patients reported:

• Strained communication and power imbalances shaped a process of mutual racialisation by patients and staff
• An absence of safe spaces to discuss racialisation silenced and isolated patients
• Not reporting racialisation and discrimination made patients feel ‘othered’, misunderstood, disempowered and fearful
• This perpetuated racialisation prevented authentic feedback from patients and disrupted the formation of trusting therapeutic relationships

‘Power imbalances’ in wards prevented authentic feedback

The authors of the paper conclude that the “culture of silence, non-reporting and power imbalances in inpatient wards perpetuated relational racialisation and prevented authentic feedback and staff–patient rapport.”

Professor Kam Bhui, senior research fellow at the University of Oxford and a co-author on the study, said that the findings were “alarming,” adding: “When people feel unsafe on wards due to racism, they are silenced. We must be courageous and ask questions because if we don’t it hurts patients and staff, and costs lives, money, and quality of life. This must change if we want to have a genuinely modern, inclusive, and effective mental health service.”

Dr Sarah-Jane Fenton, a lecturer in mental health policy at the University of Birmingham, also a co-author on the study,   said that the research was useful in two ways: “Firstly the methods used advance our understanding of realist approaches to qualitative secondary data analysis, and secondly the model presented indicates how individuals’ experience of care and racism impacted their ability to give authentic feedback. Developing a better understanding of such processes will facilitate more constructive conversations about racism and enable us to think of new ways to tackle poor experiences and improve the quality of care in inpatient mental health settings. We now need larger-scale studies to further investigate racialisation in the staff-patient relationships and its impact.”

Dr Sania Shakoor, co-author and a lecturer in mental health at Queen Mary University of London, said that the research “emphasises the need for safe spaces to discuss racialisation and help improve strained communication and power imbalances between staff and patients.”

The paper’s authors say that their findings have implications for policy. NHS trusts could, the argue, “receive further training on the effects of racialisation on authentic patient feedback.” They also recommend that future research “could be used to validate the programme theory of racialisation that was produced in this study and explore its relevance and generalisability to other contexts, with a view to developing preventive interventions.”