Professional experiences on use of the mental health act in ethnically diverse populations: a photovoice study
Authors: Bhui Kamaldeep , Mooney Roisin , Joseph Doreen , McCabe Rose , Newbigging Karen , McCrone Paul , Raghavan Ragu , Keating Frank , Husain Nusrat 
Published: October 2024

Background

There are long standing ethnic and racial inequalities in experiences and outcomes of severe mental illness, including compulsory admission and treatment (CAT).

Objectives

To gather professional experiences about a) remedies for ethnic inequalities in the use of the Mental Health Act (1983, 2007;MHA); b) recommendations for improving care experiences and for reducing ethnic inequalities.

Method

We undertook a participatory research process using photovoice to gather experience data. Photographs were assembled and narrated by 17 professionals from a variety of disciplines. We undertook thematic analysis.

Results

Ineffective communications between inpatient and community services, insufficient staff capacity, a lack of continuity of care, and language and cultural constraints meant MHA assessments were lacking information leading to elevated perceptions of risk. Practitioners felt helpless at times of staff shortages and often felt CAT could have been prevented. They felt voiceless and powerless, and unable to challenge stereotypes and poor practice, especially if they were from a similar demographic (ethnicity) as a patient. Interdisciplinary disagreements and mistrust led to more risk aversive practices. The legislation created an inflexible, risk averse and defensive process in care. Police involvement added to concerns about criminalisation and stigma. There were more risk averse practices when team members and families disagreed on care plans. More rehabilitation and recovery orientated care is needed. Legislative compliance in a crisis, conflicted with supportive and recovery orientated care.

Conclusion

Clearer standards are needed including specific protocols for MHA assessment, police interactions, considering alternatives to admission, early intervention and continuity of care.

What is already known on this topic

The Levels of compulsory admission and treatment (CAT) are rising, and ethnic and racial disparities in level of detention persist. Practitioners’ experiences of using mental health legislation holds valuable information on how to reduce ethnic and racial disparities, yet their views are rarely sought for innovations in policies and practice.

What this study adds

Practitioners identified several reasons why ethnic and racial disparities persist, including increased risk perception due to interdisciplinary mistrust and poor communication, family discord, and a lack of information due to language and cultural constraints. Police involvement led to escalation, and police and mental health practitioner roles were not always clear, leading to frustration. The emotionally demanding work of caring for people with severe mental illness, and then undertaking CAT often involved disagreement and lead to fatigue and failures to consider all options at the time of assessment. Defensive practice, delays in assessment, a lack of continuity of care, and staff shortages all add to imperfect decision making and escalation to CAT rather than other options.

How this study might affect research, practice or policy

Improving legislation alone will not reduce ethnic and racial disparities in CAT, rather a comprehensive range of community services, skilled interdisciplinary communication and decision making, less escalation to police involvement, and tackling staff shortages are all essential. Culturally competent care also requires better skills in assessing across language and cultural barriers, as well as involving family in decisions.