Diversity & Equality in Health and Care Open Access

Recently, the Sainsbury Centre for Mental Health held a day conference on early intervention for psychosis, looking at the issues surrounding the mental health of young people and what can be done to spot early signs, teach young people about emotional and psychologicalwell being, and improve services both statutory and voluntary.Amongst the speakers therewas a charismatic head teacher, talking about emotional literacy and describing the fight he had had in various schools to get young people, their teachers and parents, to recognise that issues to do with mental well being were important, and could have a lifelong impact. The conference attracted a wide mixture of people, including those who had spent their entire working lives in child and adult mental health services, as well as those who had more to do with the care system and the prison and criminal justice system.

I was only there for the opening and welcome, and I simply recited the appalling figures showing low attainment for children and young people in our care system, their over-representation in the criminal justice system in later life, and especially in our prisons. I talked of how those leaving care and those in our prisons as young offenders have a dramatically high incidence of mental illness. For most people there, these were not new statistics, but they are undeniably shocking. Amongst the terrifying data are statistics showing that over half those aged under 18 in custody have been in the care system or have had social services involvement, around 85% of young prisoners (aged 16–20) show signs of a personality disorder, and 10% signs of a psychotic illness. Meanwhile, over 50% reported drug dependence in the year before imprisonment. If one examines prison statistics overall, then black prisoners are proportionately vastly over-represented. Imprisonment rates for black people are 1140 per 100 000 of the population, compared with only 170 per 100 000 for whites. (If white people were imprisoned at the same rate as black people, England and Wales would have 400 000 people in prison.) In 2001, there were more African-Caribbean entrants to prison (11 500) than to UK universities (8000).

Quite apart from the horrifying nature of these statistics, there is something here that ought to move us to action about young people, black people, and their mental health and their behaviours. Those who run services for these groups need to reflect on their lack of progress in changing that picture. One would have to be an innocent abroad not to recognise the immense suspicion with which most mental health services are regarded by young black people. The work of the Sainsbury Centre around ‘Breaking the Circles of Fear’ made that quite clear. Young and not so young black people do not trust the system, whilst those who work within the system are all too often frightened of what they see as large, aggressive, untamed black males with mental illness, causing trouble on the wards. There is a culture of fear on both sides in this country – those who need help and those who are supposed to give it. So it is hardly surprising that so many of those in the prison system are youngish, black, with a history of some kind of mental illness, often untreated.

So what can we do? There are new avenues open to us. Assertive outreach, with young workers reaching out to young, often black, people in trouble, has demonstrated some good results. People needing help get offered assistance with money, housing, and daytime activities, in exchange for complying with treatment, and recognising that they need it. Those workers who have had or still have mental illness have shown that it is possible to take a different approach.

But what happens before they are old enough to be in the adult mental health system or in the prison system? What happens in the children’s homes or in foster care? Some young people, who had been in and out of children’s homes, whose stories I read whilst working on a book recently, argued that people tried too hard in those homes to ‘mess with one’s head’. They were always providing counselling, support, and other psychological interventions. But they did not provide stability, a sense of real belonging or, formany of them, any consultation about where they were to move on to, and when, and what conditions they wanted or did not want. Indeed, the accusation all too often was that too much ‘emotional stuff ’ was in the air, whilst what was really needed – and desired – seemed beyond the staff ’s comprehension.

When the BBC looked at some of this for a special series, most people who responded agreed that stability had often been missing, plus people who would be there ‘for you’, whatever. David Akinsaya, now a successful BBC journalist, argued that the one social worker who had real faith in himand continued to see him even when he was in prison, in her own time, made the difference to him. But she was exceptional. Another person reflected back that it was the woman who ran the children’s home she lived in, plus a lady who lived in the village and had the girls over to tea, taught them to play Scrabble, and asked them what they wanted to do with their lives, who made the real difference, acting beyond what was required of them. What mattered was stability, people who cared, and people who would stick by you, trying to help you do what you want

This is true for all young people in care. But it is doubly true for those with mental illness or at least the early signs of it. Whilst all our children and young people need to learn about emotional literacy, and need to learn how to express feelings without aggression, young black boys, now so often the target of ASBOs, so often perceived as dangerous even within the mental health services, need all the help in those areas they can get. Assertive outreach has taught us that we can reach difficult, apparently aggressive, unresponsive troubled young men- if we go about it the right way. Yet surely the message of all this is that we should get in there earlier. Surely the lesson is thatwe have to improve our care for young people in care and out of it, in prisons and before they get there. We have to change our child and adolescent mental health services to make them attractive and appealing, and we have to encourage those who work in them to be bolder and more assertive themselves. There are thousands of young people out there with early signs of mental illness and distress. Many of them are black. Some of them are refugees or asylumseekers. Their illnesses may have all kinds of contributory factors. But if we do not recognise those early signs and offer care that they actually want, we will end up slapping ASBOs on them because they behave badly – and they will end up with a lifetime of mental illness and a poor outlook – which, had we only been more sensitive and sensible, we might well have avoided.