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Centre for Applied Social and Psychological Development, Salomons, Canterbury Christ Church University College; Health Services Research Department, Institute of Psychiatry, De Crespigny Park, London SE5 8AP,
Henderson Hospital and St George’s Hospital Medical School
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Abstract |
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 Top Abstract IntroductionAimsMethodResultsDiscussionReferences |
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All mental health services are expected to aim for equality of access to people from minority ethnic groups. Psychotherapy services typically have a low proportion of ethnic minority clients. Specialist services such as therapeutic communities are no exception. It is also possible that ethnic minority residents are more likely to leave group treatments early if they are clearly in the minority. The study examined records between 1996-2000 to ascertain whether ethnic minorities show a different pattern of exit from the process than people from other backgrounds.
RESULTS
Just over 9% of referrals to Henderson Hospital were from ethnic minorities. Ethnic minority referrals were less likely to be invited to a selection interview. However, there was no difference in length of stay in treatment. There was a trend towards ethnic minority referrals having more severe symptomatology and histories than those from White backgrounds.
CLINICAL IMPLICATIONS
Ethnic background should be taken into account when considering referral for specialist psychotherapy. Routine monitoring of the processing of ethnic minority referrals should be conducted in all psychotherapy services.
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Introduction |
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The prevalence of personality disorder in the UK is between 4-33% (Hobson, 2000), and increases with the level of health service setting from 13% of general practitioner (GP) clients to 40-50% of in-patient psychiatric patients (Casey & Tyrer, 1986, Casey, 1988). There are no figures relating to ethnicity (Ndegwa, 2003). Black clients are less likely than White to be diagnosed with personality disorder, and more likely to be diagnosed with schizophrenia (Strakowski et al, 1995).
Ethnic minorities are over-represented in psychiatric services (London, 1986) and especially in compulsory psychiatric care (Ineichen et al, 1984). This Bristol study found that ethnic minorities accounted for 17% of voluntary and 36% of compulsory psychiatric admissions. Conversely, ethnic minorities are under-represented in specialist psychotherapy services (Campling, 1989) and are less likely than White clients to be offered counselling (32% v. 75%) (Alexander, 1999) or psychological therapy (Commander et al, 1999).
It has been suggested that the therapeutic community, such as that at Henderson Hospital, is a suitable treatment model for ethnic minorities, and that while only 1 in 50 (2%) referrals in 1991 were from ethnic minorities, the appropriateness of the treatment to the client group had not been widely recognised (Dolan et al, 1991). The beneficial treatment effect of Henderson Hospital is positively correlated with increasing length of stay (Dolan et al, 1997). Therefore, as a general rule, the longer residents can be maintained in treatment, the better. Research on the staff team at Henderson Hospital found that they considered that being in any kind of minority (including ethnicity) is a risk for leaving early (Blount, 2001). Were the therapeutic community less appropriate for people from different cultural groups, it might be expected that those people from different cultural groups would stay less time in treatment than those from the White groups.
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Aims |
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Method |
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A client must be selected before they can be admitted to the hospital. The selection group comprises three staff members and nine current residents in the therapeutic community, and decisions to offer admission are made by democratic vote.
Clients can exit the process at three stages (as shown in Figure 1):
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Sample
Consecutive referrals, selections and admissions between 1 April 1996 and
31 January 2000 (n=792) provided the sample for this study.
Data source
The data derive from the information supplied by the referrer on a standard
form, the Referral Information Form, for each client. The form records 32
variables related to social, psychiatric and criminal histories, as well as
psychological symptoms of the candidate. These variables are dichotomous and
the referrer reports whether the variable is present or absent. The variables
were as follows: depression; anxiety; panic; obsessions; deliberate self-harm;
phobias; eating disorder; alcohol misuse; drug misuse; gambling;
self-mutilation; attempted suicide; overdosing; mania/hypomania;
delusions/hallucinations; violence to others; violence to property;
firesetting; theft/shoplifting; physical abuse; sex (victim); sex
(perpetrator); dissociation; physical illness; registered disabled; any
psychiatric treatment; child therapy; ever convicted; on probation now; court
case outstanding; taking medication. As can be seen, some of these variables
overlap. This is a consequence of old and new forms being logged on the same
database. In the cases where the category was no longer used, it was scored as
missing.
Ethnicity data
The ethnicity information used in this study came from the Referral
Information Form. The ethnicity categories were those routinely used by the
hospital and recommended by the Department of Health at the time of the data
collection. These were as follows: White, Black African, Black Caribbean,
Black Other, Chinese, Asian Other, and Other Ethnic Group. It is to be assumed
that those candidates described as ‘other ethnic group’ were not
considered by their referrer to be suitably described by the other available
categories.
As the form was completed by referrers, this information is their opinion of the client’s ethnicity. There is no way to tell whether or not the referrers asked the client about their ethnicity. The ethnicity question was often not completed, and so there was a large amount of missing data (10%). Every effort was made to recover this data. After the search was completed, there remained 79 cases with missing ethnicity information. These cases were not included in the statistical analyses.
Data analysis
Data were analysed using the Statistical Package for the Social Sciences
(SPSS) version 10 for Windows
(Noru
is, 1988). T-test
was used to analyse length of stay. Pearson’s 
2 was used
to analyse outcome at each stage of the referral process, and the relationship
between ethnicity and clinical history. Thirty-two 2 tests
were carried out to see if there was any association between ethnicity and
presence or absence of these histories. The Bonferroni correction (corrected
critical value of P=0.00156) was used to correct for Type II
error.
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Results |
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TopAbstractIntroductionAimsMethodResultsDiscussionReferences |
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Stage one: the initial decision of the referral group
A selection group was offered to 501 candidates
(Table 2). 2
tests showed that proportionally, fewer of the ethnic minorities
(n=44/74; 59.5%) were offered a selection interview than White
candidates (n=457/639; 71.5%) by the referral group
2=4.389, df=1, P=0.036.
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Stage two: the selection group
Selection groups were held for 395 candidates. This figure comes from those
selection groups that actually took place during the time period under study,
rather than those that were offered. There was a non-significant trend for
White candidates to be more likely to attend the selection group than ethnic
minority candidates (n=356/639; 55.7%, v. n=39/74;
52.7%, 2= 3.158, df=1, P=0.076, ns).
Stage three: residential treatment
Two hundred and thirty-seven candidates were admitted. Of these, 211 (89%)
were White and 26 (10.9%) were from ethnic minority groups, showing that White
candidates were in a numerical majority within the resident group. However,
the likelihood of being admitted following referral was of a similar level
across ethnicities (n=211/639; 33% v. n=26/74;
35%).
Length of stay varied widely for the whole group. For both the White and minority admissions, the shortest length of stay was one day. The longest length of stay for minority residents was 377 days and for White residents 379. No significant difference in length of stay was found between length of stay of White and ethnic minority residents (mean=149, s.d. 139.67 days v. mean=143, s.d. 140.17 days; t(235)=–0.196, P=0.844, ns).
Clinical and demographic factors
These 32 factors were examined to see if there was any association between
ethnicity and previous symptomatic, psychiatric and criminal histories, as
reported by the referring clinician. A corrected critical value of
P=0.00156 was found. Using this value, no significant associations
were found. Prior to the Bonferroni correction, three associations were found
to be significant at the P=0.05 level. These cannot be viewed as
significant as they do not meet the corrected P value, but they are
of interest as possible underlying trends. Ethnic minorities were more likely
to have had eating disorders (2=5.421, df=1, P=0.020,
ns), were more likely to have misused drugs (2=5.519,
df=P=0.019, ns) and were more likely to have had a history of
gambling (2=7.503, df=1, P=0.006, ns).
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Discussion |
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TopAbstractIntroductionAimsMethodResultsDiscussionReferences |
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Being in an ethnic minority was significantly associated with rejection by the referral group, the first stage of the referral process. Two possible explanations for this were that the referral group was rejecting ethnic minority candidates because of their ethnicity, or there were other variables incidentally related to these candidates that led to the rejection, such as more severe clinical presentation. The majority of referrals were excluded automatically according to criteria of suitability, indicating that ethnicity per se was not a factor. However, a possible confounder is that one of Henderson Hospital’s exclusion criteria is psychotic illness, which has been established to be diagnosed more frequently in non-white psychiatric patients.
Ethnic minority referrals tended to have more severe clinical factors (eating disorder, gambling, drug misuse). The rejection at stage one could be because ethnic minority referrals are more severely disturbed by the time they get referred for specialist treatment. Given the small sample of ethnic minority referrals, it is not possible to rely on these data, but further exploration of these issues is indicated by the non-significant trends.
An important finding is that the length of stay at Henderson Hospital is unrelated to ethnicity. The Henderson Hospital staff team’s perception that being in an ethnic minority would be a risk for early drop out (Blount, 2001) was not borne out by the results. In addition, this would suggest that the treatment is as suitable for those referrals from White and non-White groups.
Limitations
The principal drawbacks of this study were the amount of missing data, the
reliance of ethnicity information supplied by the referrer rather than the
client and the small sample of non-white referrals. The small sample sizes are
inherent in this kind of work, however, given the small number of clients from
ethnic minority backgrounds who are referred to tertiary psychotherapy. It is
also difficult to assess the importance of any changes over time in referral
rates to specialist services without knowledge of changes in the base rates
within the population from which referrals come. The methodology, and any
future exploration of cultural issues in this context may be improved by the
addition of a qualitative approach to assessment of the cultural relevance of
this treatment approach, including an exploration of the experiences of this
treatment of clients from ethnic minority groups.
Conclusion
Despite the low numbers of ethnic minorities involved, this study suggests
that, once offered selection, ethnic minority referrals are no more nor less
likely than White referrals to be selected, admitted, or stay longer.
Clinical and research implications
This study suggests that ethnic minority clients may not be referred for
specialist treatment until they have more severe difficulties than their White
counterparts. Further research with larger sample sizes and including a range
of psychotherapy services should be conducted to explore this finding and the
reasons for it. The study also suggests that therapeutic community treatment
is appropriate for clients from minority backgrounds, and that they are as
likely to be admitted and remain in treatment as long as White clients.
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Acknowledgments |
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References |
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TopAbstractIntroductionAimsMethodResultsDiscussionReferences |
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BLOUNT, C. (2001) An investigation into why people drop out of therapeutic community treatment. Exploring the connection with crime. Unpublished dissertation, University of Surrey.
CAMPLING, P. (1989) Black people and psychiatry.
Psychiatric Bulletin,
13, 550
-551.
CASEY, P. R. (1988) The epidemiology of personality disorder. In Personality Disorders: Diagnosis, Management and Course (ed. P. Tyrer). London: Wright.
CASEY, P. R. & TYRER, P. J. (1986) Personality, functioning and symptomatology. Journal of Psychiatric Research, 20, 363 -374.[CrossRef][Medline]
COMMANDER, M. J., COCHRANE, R., SASHIDHARAN, S. P., et al (1999) Mental health care for Asian, Black and White patients with non-affective psychoses: pathways to the psychiatric hospital, in-patient and after-care. Social Psychiatry and Psychiatric Epidemiology, 34, 484 -491.[CrossRef][Medline]
DEPARTMENT OF HEALTH (2000) The NHS Plan. A Plan for Investment, a Plan for Reform. London: DoH.
DOLAN, B., POLLEY, K., ALLEN, R., et al (1991) Addressing racism in psychiatry: is the therapeutic community model applicable? International Journal of Social Psychiatry, 37, 71 -79
DOLAN, B., WARREN, F. & NORTON, K. (1997) Change
in borderline symptoms one year after therapeutic community treatment for
severe personality disorder. British Journal of
Psychiatry, 171, 274
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HOBSON, T. (2000) Managing personality disorders within local mental health services. Dialogue, 5, Autumn/Winter. Henderson Hospital.
INEICHEN, B., HARRISON, G. & MORGAN, H. G. (1984)
Psychiatric hospital admissions in Bristol 1. Geographical and ethnic factors.
British Journal of Psychiatry,
145, 600
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LITTLEWOOD, R. & LIPSEDGE, M. (1989) Aliens and Alienists: Ethnic Minorities and Psychiatry, 2nd edition. London: Unwin Hyman.
LONDON, M. (1986) Mental illness amongst immigrant
minorities in the United Kingdom. British Journal of
Psychiatry, 149, 265
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NDEGWA, D. (2003) Personality disorder in African and African-Caribbean people in the UK. http://www.doh.gov.uk/mentalhealth/pdndegwa.pdf. Accessed August 2003.
NORU
IS, M. J. (1988) Introductory
Statistics Guide for SPSS. Chicago: SPSS Inc.
STRAKOWSKI, S. M., LONCZAK, H. S., SAX, K.W., et al (1995) The effects of race on diagnosis and disposition from a psychiatry emergency service. Journal of Clinical Psychiatry, 56, 101 -107.[Medline]
WARREN, F. & DOLAN, B (eds) (2001) Perspectives on Henderson Hospital, 2nd edition. Henderson Hospital: Surrey.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
