4.
The project builds upon a range of policy and guidance documents that actively seek to promote and
support the mental health and well being of elders. These include
• A new ambition for old age: next steps in implementing the NSF for older people (DH 2006a)
• Let’s Respect (CSIP 2006)
• A sure start to later life: ending inequalities for older people (ODPM 2006)
• Promoting mental health and wellbeing in later life (UK Inquiry into Mental Health and Well‐Being
in Later Life 2006)
• National service framework for mental health – five years on (DH 2004)
• National service framework for older people (DH 2001a) Mental wellbeing in older people
• National service framework for mental health (DH 1999)
• Our health, our care, our say: a new direction for community services (DH 2006b)
• Making it possible: improving mental health and wellbeing in England (DH 2005a)
• Independence wellbeing and choice: our vision for the future of social care for adults in England(DH
2005b)
• Securing better mental health as part of active ageing (DH 2005c)
• Fair access to care services (DH 2002)
• Building capacity and partnerships in care (DH 2001b)
• Everybody’s business – integrated mental health services for older adults (DH/ CSIP 2005)
• Opportunity age – meeting the challenge of ageing in the 21st century (DWP 2005).
This report:
This initial report is the first step in the one year project and it seeks to
a) Examine some of the key debates in the field of BME older people’s mental health and
b) To map key mental health projects and resources for black and minority ethnic elders across England.
9.
o People from minority ethnic groups are less likely to use health and social care services and
are often less aware of what help is available (Ahmad et al 2000).
o The Health Survey of England (1999) reports that South Asian men and women as well as all
Black Caribbean women aged 55+ report relatively high levels of limiting longstanding illness
compared to the general population (Patel, 2003: 21 cited in PRAIE 2007).
o Differing religious and cultural practices appeared to affect the way in which participants
were prepared to comment negatively on their current quality of life. This may be especially
noticeable among some Muslims who might emphasise that there was a divine purpose
behind an event (Fisher et al 2006
Ageing and culture
Interestingly the literature of ageing and culture addresses the issues of ‘cultures of ageing’ as well as
‘ageing within different cultures’
Cultures of ageing.
There is an extensive literature on cultures of ageing and much of this focuses on how becoming older in
itself creates a different cultural identity. This literature / research reflect the demographic changes as
we start to become an increasingly ageing population and it embraces ideas about how culture shapes
our experiences of ageing (Torres 1999, Twigg 2004). There are many theories of ageing, although most
of them seem to be Eurocentric in focus.
• The 1950s saw beginnings of theoretical debates about ageing and society and in particular
about people’s loss of role following retirement and how this presented a problem for society
(Jones 1993). One influential theory was ‘disengagement theory ‘ that suggested how older
people should disengage from work roles and prepare for the ultimate disengagement of death
(Cumming and Henry 1961).
• Later political economists such as Walker and Townsend ( 1981) saw age in relation to advanced
capitalist economies and how the experiences of different elders related to their class positions
during their working lives. Walker in particular was interested in how the State created a
situation of dependency for working class elders and this was seen as a reflection of the
inequalities of class and employment opportunities.
• Other debates in gerontology examined the construction of age. The work of Gubrium (1975)
was important in his analysis of Alzheimer’s disease in the USA and the establishment of
boundaries between ‘normal’ and pathological aging, where old age is seen as a "mask" which
conceals the ‘essential’ identity of the person beneath. Later these ideas were extended by
Featherstone and Hepworth who suggested that age should be viewed as fluid. They also
critiqued the medical model of ageing as a process of decline (1993).
13.
• The lack of a professional interpreting service may make it difficult for assessors who do not
speak the older person's preferred language to conduct an effective assessment. The use of
friends or family members as interpreters may compromise confidentiality or influence the
assessment. Older people affected by dementia, who were once able to speak English as a
second language, may lose the skill as their memory deteriorates. Even with good language
skills, cultural differences may result in meaning and nuance being lost.
• Standard diagnostic tests for dementia, or depression, may not be culturally appropriate and
may lead to inaccurate diagnosis.
• Assessors may not be able to offer a sensitive and effective assessment because they are not
sufficiently familiar with the lifestyles, health, religious and cultural needs of older people and
their carers from minority ethnic communities.
• No suitable services may be available where the older person's language is spoken and their
cultural, religious and dietary needs met.
• Conversely, assessors may make assumptions about the lack of acceptability of mainstream
services to older people and their families, and not offer them.
Screening BME elders
While research suggests that BME elders may have a range of mental health needs, the process of
identifying needs through standardised assessment. There is conflicting research evidence on the
cultural appropriateness of mental health screening and assessment tools. As an example of this
conflicting evidence, what follows is an illustration of the research based on the Mini‐Mental State
Examination (MMSE), this is a brief assessment instrument used to assess cognitive abilities in the
elderly and is the most commonly used test for complaints of memory problems or when a diagnosis of
dementia is being considered. While some research suggests that this tool is culturally transferable (this
includes when the MMSE has been translated into different languages), other research appears to
suggest that assessment tools such as the MMSE are not transferable across cultures. Example of these
studies include
• Research by Lindsay et al (1998) aimed to evaluate the performance of a Gujarati version of the
MMSE. The effect of ethnicity on MMSE performance was also examined. The results suggested
that the Gujarati version of the MMSE performed adequately as a screen for dementia in this
immigrant community population.
• Research by Kabir and Herlitz (2000) adapted the MMSE for the cultural context of Bangladesh
and for use in populations irrespective of literacy skills. In the Bangla Adaptation of Mini‐mental
State Examination (BAMSE), the MMSE items were changed in such a way that they would be
applicable for illiterate individuals, as well as being culturally relevant in Bangladesh. To enable
comparison between the BAMSE and MMSE, the literate elderly were tested with both
instruments. The results showed that, in comparison to the MMSE, the BAMSE demonstrated
satisfactory test properties, although reliable differences were found on some of the individual
items when the two instruments were compared. More importantly, the BAMSE was found to
be less sensitive to age and education than the MMSE. Finally, the results suggest that in the
21.
rates of depression (up to 90%), with major depression accounting for over 50% and physical
illness being a significant contributor in around 60–70% of cases
• The role of social isolation as a risk factor for elderly suicide
has been stressed in many studies.
(Barraclough 1971), for
example, living alone as often cited as the most important social
variable.
• Effective suicide prevention models will involve multi faceted prevention strategies carefully
designed to address the needs of the individual (Diekstra, R. F. W. 1993).
• Investment in supporting community outreach and voluntary sector groups with a prevention
and promotion focus will enable the overall needs of vulnerable people to be addressed and
thereby reduce the likelihood of their needing support from specialised mental health services
(NIMHE and NatPAct 2005) The Commissioning Friend for Mental Health Services
http://www.natpact.nhs.uk/uploads/2005_Jan/MH_Print_Version.pdf
Suicide and BME elders
• Burr (2002) warns that some times cultural stereotypes have been presented as scientific facts,
hence the South Asian patient's experience of depression followed with suicidal thoughts and
intent is attributed solely to the person's culture.
• In some cultures suicide may be an acceptable way to avoid losing face and honour, in other cultures it
may be viewed as a grave sin that will bring shame and disgrace on the family for many years
(Farberow, 1975).
• Community education and awareness programs need to take into account these different values and
attitudes towards suicide and present information and support in ways that are culturally and
linguistically appropriate. Farberow (Ed.) (1975).
• Improving information and pathways to care, supporting self‐help groups and BME elder community
organisations may all provide early interventions that may prevent mental health problems escalating.
Spirituality
For many people, their spiritual life is significant to their mental health and well being and practitioners
are now recognising the value of spiritual life to mental well being and recovery across all different
cultures (Cinnirella et al 1999, Larson 1998).
The Royal College of Psychiatry, has identified that spiritual care can have a very positive outcome for
many people, ( see also the NIMHE spirituality project) and a number of studies have highlighted the
importance of religious and cultural values for minority ethnic families. Beliefs and values are often
integral to people’s self‐concept and will affect their willingness to take up any services on offer (Azmi et
al 1997).
22.
Attention to cultural practices and religious beliefs is important in the
achievement of quality in service provision and beliefs can offer many people
solace, and spiritual nourishment as well as a framework for daily living.
• Working in partnership with local religious and spiritual groups can be
an effective approach to mental health promotion.
• Spiritual leaders are widely consulted by individuals experiencing
mental distress and this may reflect the help‐seeking behaviour in
many different cultures and may appear more culturally appropriate as a first place for
information and support.
• A person’s spirituality may also inform their perceptions of experiences and an event, including
emotional distress and mental ill health and it is important that these spiritual needs are
recognised in the development of culturally sensitive services.
• Research suggests that older people who have a strong sense of spiritual belief and personal
meaning in life are less likely to suffer from depression or mental health problems even when
they have lost a spouse within the past year and spiritual practice may help to support the
mental health and well being of elders who have been bereaved (Coleman et al 2002)
While it must be acknowledged that culture (including spiritual beliefs) can impact on a persons life
and health, it is important to recognise that the social determinants of health other dynamics may
also prevent the use of services on offer such a language barriers, lack of understanding of services
available and concern about stigma.
Accessing mental health services
People with mental health problems pass through different levels of ‘filters’ before gaining access to
different levels of mental health services (Goldberg and Huxley 1980). Pathways to mental health
services may be influenced by a number of factors including the cultural appropriateness
of services
(including access to interpreters and health practitioners who can speak the clients language); attitudes
towards services; previous experiences;
and culturally defined lay referral systems( Goldberg 1999).
While much of the literature on mental health focuses on the medical model there is a growing interest
in how socio‐cultural factors may mediate the experience of, and response to illness such as dementia
(Holstein 1998) and how different cultures perspectives may influence help seeking behaviour (Radley
1987)
Some of the barriers to accessing mental health services include:
Communication
• Research suggests that one of the primary challenges facing BME service users in trying to
access mental health services is language (Tribe and Raval 2002)
23.
• Although clients and interpreters speak the same language they may or may not share the same
cultural origins. Practitioners need to be sensitive to cultural issues such as the religious
background, ethnic group, political alliances or the cultural origins of the interpreter / client.
mmmm
• These issues can be complex to resolve as the client may, or may not, want the interpreter to come
from the same background (e.g. religious background). This issue needs to be handled with
sensitivity, as a service provider needs to conform to the Race Relations Act as well as being
receptive to the needs of their clients.
• A competent interpreter in mental health is not only a language broker but also a cultural broker, as
the task of the interpreter is to facilitate communication. The interpreter must know not only the
meaning of words in another language, but must also understand the meaning of concepts in both
cultures. However, although the interpreter may be asked about cultural background issues, the
practitioner needs to be aware that if the interpreter is not from the same clan, class, gender,
religion or culture to the client then they may not be able to answer / support cultural
interpretation issues (Tribe and Raval 2002).
• Research suggests that it is unrealistic to imagine that people who have reached a certain level
of maturity can learn a new language (PRAIE 2005)
• Some BME older peoples may not speak English and a number are illiterate in their own
language this may be due to work patterns and family commitments (McCallum, 1990)
• Deaf people are over‐represented in the mental health setting. A deaf person may have limited
opportunitiesto get to know where and how to get help for mental health problems. There may
be cultural differences in the way mental distress manifests in people who are deaf, compared
to those who are not. One difference in working with a deaf client is that the interpreter is
usually hearing, so will not share the same cultural background as a deaf person. This can bring
the issue of mistrust towards both the interpreter and the mental health professional. It may
be difficult to find an interpreter for the deaf in the language for some BME service users.
Stigma
• Research by Seabrooke and Milne (2004) in Kent explored the service‐related needs of Asian
older people with dementia and their carers. Currently Asian elders and their carers are only
willing to use services where their cultural and linguistic needs are met. Unfortunately such
services are generic and are neither appropriate nor resourced for managing people with
dementia. GPs also have difficulty with diagnosing dementia in Asian elders, and families are
reluctant to come forward for treatment due to community stigma.
• Research suggests that there is a lack of awareness regarding definition and recognition of
dementia in BME communities and a greater need for community education to reduce stigma
and myths ( Hare 2001).
• It is possible that levels of stigma about mental health are higher in some communities than
others (Ng, 1997; Marwaha and Livingston, 2002; Bowes and Wilkinson, 2003).
24.
• Some BME communities may not access services, due to a
belief that the rest of their community might think they are
not capable, lacking as a family or seeking charity. There is a
also a lack of awareness among some BME people concerning
of the role of the GP as a source of information and support
for mental health problems (Jacob et al, 1998).
• People express their distress and pain in different ways and
hold diverse beliefs about the body, healing and sickness (see
culture section above)
Attitude of service providers
• Research by Odell suggests that GPs by are less likely
to
identify psychological symptoms in ethnic minority patients
(Dell et al 1997) and there may be a tendency among some
GPs to perceive the health needs of their minority ethnic
patients on the basis of negative stereotypes (Ahmad et al,
1991).
• Research suggests that black and Asian ethnic minorities,
access to, utilisation of
and treatments prescribed by mental
health practitioners differ from
those for white people (Lloyd
and Moodley 1992).
• Like all elders, research suggests that BME elders wish to
being treated with respect; feel safe and comfortable; having
their dignity respected; and be supported by professionals
who behave with integrity (PRAIE 2005). However, practitioners may need to consider how
these attributes are interpreted and experienced across cultures.
BME service users, families and carers.
Service users and their carers are the most important people in the health service; involving them in service
planning and delivery is one of the main ways we can make sure that we offer patients the highest quality
care. Patient and Public Involvement is about making improvements to patient care, by enabling patients to
have a say in how they are treated and how services are run. Under the NHS Plan, health trusts now have a
legal duty (under Section 11 of the Health and Social Care Act 2001) to consult patients and the public in the
planning of services. Patients and the public should be involved and consulted from the very beginning of any
process to develop or change health servicesi
. This will increasingly lead to a more patient‐centred health
service and improvements in the patients’ experience. This is not about new targets; it is about delivering
what the patient thinks is acceptable and needs.
’ Traditionally, there has been a
view that black and minority ethnic
communities do not wish to use
services, as they prefer to care for
elders themselves. However,
research suggests that the idea that
the extended family will look after
their elders may be a myth and that
in many cases the reality is that
family networks are spread across
continents not counties. Similarly,
black and minority ethnic
communities are often described as
a hard to reach group. An
alternative view is that these
communities find services hard to
access.
The number of older people from
black and minority ethnic
communities has risen sharply over
the past few decades and is
projected to continue to rise. Black
and minority ethnic older people
with mental health problems and
their carers need to have access to
appropriate and responsive services.
There needs to be a balance
between ensuring access to
mainstream services and
understanding the nature and
extent of the need for specialist
services’’.
Everybody’s Business (DH/ CSIP
2005)
26.
• Patients and carers are not often accommodated in the formal system of care because service
providers believe that people from minority ethnic communities find these services as either
inaccessible or inappropriate to their culture specific needs (Forbat 2003)‐ as a result BME
service users and their carers may become locked out of care
• Many elders who live in the UK due to forced migration (i.e. refugees) may not have any family
in the UK (Connelly 2006).
• Research suggests that carers of people with learning difficulties from minority ethnic
communities are often more affected than their White peers by problems of poverty, bad
housing financial problems and racism (Butt and Mirza 1996).
• Some elders who are unable to speak English may be dependant on other family members for
accessing the most basic services, which can place a strain on the family and create a sense of
loss of independence in the older person and some elders who have used English in the past
may return to their original language of their childhood.
Part two: Issues for specific BME elder
communities
Lesbian, gay, bisexual and transgender (LGBT) BME elders
As with all community groups, lesbian, gay, bisexual and transgender
(LGBT) BME elders need to be approach as unique individuals with
distinctive needs. While living life openly as a lesbian, gay man or
bisexual person is only a relatively recent possibility (Heaphy et al.
2003; Weeks 1995, Plummer 1995; Weeks et al. 2001), policy and
service provisions for ageing LGBT communities are slowly developing to recognise the needs of the individual
within these communities. However, while there is very limited research on LGBT elders, there is even less
research about BME LGBT elders.
The general research suggests that
• Many of the health and social care needs of older people who are lesbian, gay, bisexual or
transgender are likely to be the same as other older people although they may face additional
discrimination.
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
• Ageing can have a significant impact on how individuals live their lives as lesbians, gay men and
bisexuals in a predominantly heterosexual society and this may contribute towards a sense of
isolation and loneliness (Heaphy et al 2003).
• Lesbian and gay communities may have an important role in supporting non‐heterosexual
identities and ways of living. However, these community supports are unevenly distributed in