Journal of Community & Applied Social Psychology 9: 101-117 (1999)

'You've Got to Have a Chinese Chef to Cook Chinese Food!!' Issues of Power and Control in the Provision of Mental Health Services

I. A. FATIMILEHIN and P. G. COLEMAN

Royal Liverpool Children's N.H.S. Trust, Child and Family Services Central Team, 41-43 Seymour Terrace, Seymour Street, Liverpool L3 5TE, UK

ABSTRACT

This paper examines issues of power and control in mental health service provision, as discussed by African-Caribbean parents within a series of focus groups. These issues are multi-faceted and incorporate aspects of confidentiality, stigmatisation, accessibility and ethnic matching. The impact of migration and the option of community self-reliance are discussed, along with implications for the provision of mental health services.

Key word,: African-Caribbean families; mental health service use; power; ethnic minorities

INTRODUCTION

Over the past 20 years, the fate of people from ethnic minority groups within mental health services has attracted increasing attention in the research literature (Littlewood and Lipsedge, 1997; Fernando, 1995). Major issues have included the over-representation of some ethnic minority groups in secure institutions and psychiatric hospitals, and the under-representation of Black and Asian people amongst those receiving less coercive forms of intervention.

The over-representation of people of African-Caribbean descent in secure institutions has been well-documented (Littlewood and Lipsedge, 1997; McGovern and Cope, 1987, 1991). Commander et al. (1997a) carried out epidemiological surveys in psychiatric services, primary care settings and community settings in Birmingham (a multi-ethnic inner-city area). They found that Black people were over-represented within psychiatric services when compared to Asian and White people, and that they were more likely to be admitted to hospital or detained under the Mental Health Act. Within the services in his study, Browne (1995) found that the proportion of young Black men increased as the level of coercion increased. He attributed this phenomenon to the racist stereotypes held by health staff, social services and the police. In particular, he found that 75% of all the professionals interviewed held the view that Black clients were more likely than White clients to be dangerous. Correspondingly, Black clients were more likely to have been restrained before or during admission, and were more likely to be given sedative medication.

Conversely, it has been shown that people from ethnic minority groups are under-represented in less coercive forms of treatment, such as talking therapies and psychotherapy services (Ahmed, 1995; Littlewood and Lipsedge, 1997). A number of explanations for this can be identified in the literature. Firstly, it has been argued that people from ethnic minority groups are not perceived as capable of benefiting from psychotherapeutic approaches, due to cultural and linguistic differences. For example. some researchers have suggested that Asian people have a tendency to somatize psychological distress (Bal, 1987) and this has led to a myth that they are unable to utilise talking therapies (Ahmed, 1995). Secondly, it has been suggested that people from ethnic minority groups are less likely to approach formal services when they first become aware of a problem. Research in the USA has shown that parents from ethnic minority groups are less likely than White parents to make professionals their first port of call when they are concerned about their child (McMiller and Weisz. 1996). They suggest that this may be because ethnic minority families have little confidence in the ability of the services to understand and meet their needs. and have had negative experiences with statutory services in the past. Thirdly, it has been well-documented that. for people from ethnic minority groups, there is a lack of appropriate and accessible information about existing services (Beliappa. 1991; Fatimilehin and Nadirshaw, 1994; Ahmed, 1995). This may be in terms of the very existence of the service, or in terms of what the service is able to offer. In addition. there may be language and communication barriers (Bal, 1987; Beliappa, 1991). Finally. the racist attitudes held by many mental health and primary care professionals may mean that less coercive forms of intervention are not offered at all (Littlewood and Lipsedge, 1997). Browne (1995), in the aforementioned study, suggested that perceptions of dangerousness were subject to racial bias, and affected the form of intervention offered. Similarly, other studies have shown that racial stereotypes held by mental health professionals can result in more physical treatments (such as depot medication, restraint and seclusion), rather than less coercive treatments (such as occupational. recreational and psychological therapies) for Black patients (Ndegwa, 1998). It must be borne in mind that these explanations are not mutually exclusive, but may operate additively in preventing access to early and preventative interventions. Sassoon and Lindow (1995) assert that racism is not an additional problem, but ‘an interpretive schema through which all problems are understood'.

Research investigating pathways into care has become more prevalent in recent years as one way of understanding mental health service provision. The GP acts as the main point of access for all health services in the UK; he or she makes a decision about the need for specialist care and refers the patient accordingly. Commander et al (1997b) showed that whilst Asians were more likely to have mental health problems and consult their GP than Whites or Blacks. they were also less likely to have their mental health problems recognised by the GP. The recognition of affective disorders was substantially lower for Asians when compared with Whites or Blacks. The research suggests that whilst GPs should be in a good position to engage the patient in early intervention services, this does not happen and difficulties are only detected when they have become severe. Akilu and Wildsmith (1996) have also noted that people of African-Caribbean descent have different pathways into care than White people.

The views of users and ex-users of psychiatric services are being heard with increasing frequency in recent years. Several organisations now exist through which survivors of the psychiatric system can join with others to make their voices heard and engage in collective action. Sassoon and Lindow (1995) have highlighted the fact that the voices of Black and ethnic minority survivors are not yet being heard in the user movement. They propose that some of the impediments to Black people speaking out about their experiences include the high levels of oppression that they are subject to as users, such as the prescription of high doses of medication. lack of clear communication with service providers, and fear of being sectioned. In addition, the stigma of being associated with the mental health system may be too much for those who are already in a vulnerable position in society. Involvement in the mental health system serves to further disempower people from ethnic minority groups.

The concept of empowerment has received little attention in the literature, although it is used by both users and staff within the debates surrounding mental health. Rogers et al (1997) constructed a scale which comprises five components of empowerment. These are: self-efficacy/self-esteem; power/powerlessness; community activism; righteous anger; and optimism/control over the future. Empowerment was positively related to quality of life. income and community activism. It was inversely related to the use of mental health services.

Fatimilehin and Coleman (1998) presented findings from a series of focus groups involving African-Caribbean parents. The study investigated factors affecting the low referral rate of African-Caribbean children to a Community Child and Adolescent Psychology Service. In particular, it explored participants' expectations. impressions and knowledge of clinical psychology services. especially in terms of services for children. The study also aimed to identify participants' preferences in terms of the structure and delivery of a Child and Adolescent Psychology Service. Preliminary results and service implications were reported in Fatimilehin and Coleman (1998). In this paper we wish to focus in greater depth on the issues of power and control which became evident in the focus group discussions around the use of a child and adolescent psychology service. We also wish to present some of the issues and complexities described by participants that include their own childhood experiences, and the impact of racism and migration on the ways in which they are parenting their children.

METHOD

Focus groups

There is very little research which has investigated Black people's experiences of mental health services from their own perspective. We felt it was important to use a research method which could incorporate some guidance from the available literature, with the identification and elaboration of new issues. Kitzinger (1994) suggested that focus groups can facilitate the identification and exploration of group norms and the articulation of differences between group participants. In addition. participants' attitudes. priorities. language(s) and framework for understanding the issues at stake can be privileged. The group facilitator can explore differences between participants in situ and encourage participants to reflect on each other's ideas. Focus groups have been used effectively to explore people's experiences of a service (Gregory and McKie, 1991), and can be particularly sensitive to cultural variables and work with minority groups (Jarrett, 1993).

Participant selection and access

Only parents of African-Caribbean origin who had children aged five years and above were included in the study. These criteria were set as it was felt to be important that parents should have begun to consider wider issues relating to their children's social and educational welfare. The city has a number of resources and centres that have been set up by and for Black people, and some of these are partly funded by the City and County Councils. We started by seeking permission from these organisations to recruit participants on their premises. The aims of the research were met with some suspicion within the Black community. This was partly because many Black parents had experienced negative and often traumatic encounters with statutory services, and because some community organisations felt that Black communities are approached to take part in numerous public meetings, interviews and other consultation exercises, only to receive little feedback and experience no real change. A total of 11 organisations were approached but only three of these felt it was appropriate to allow access to their users.

Prospective group participants were asked to complete a screening questionnaire that asked about our main criteria (i.e. that they should have children and be able to attend a group session). Following this letters of invitation were sent to each participant with details of the session, and phone calls were made to confirm attendance a week before the group session. All the groups were held in a community centre which was well known and in the midst of the Black community, and taxis were provided for any participants who needed them. The community centre runs educational programmes for children and adults, community events such as a yearly Black history month, a Mentor scheme for African-Caribbean children, a yearly careers convention as well as a host of other events and entertainment. A small number of participants were not recruited in the normal way (e.g. someone who happened to be in the centre as the group was starting and expressed an interest), and some of the participants brought interested friends who were also parents.

Description of participants

24 parents (62% females and 38% males) took part in a total of five focus groups: 45% of these parents were in the 30-40 year age range, and 50% had only one child; 13% of the parents were unemployed, and 54% described themselves as being in the professional/administrative occupational class. All participants had at least one child who was less than 10 years of age, and 13 parents had a pre-school child. None of the participants had used clinical psychology or psychiatry services, but one had used the educational psychology service, one was a mental health worker, and one was a primary care health worker.

Procedure for sessions

Each parent was asked to attend one focus group lasting approximately one and a half to two hours. Each of the five groups was run by a clinical psychologist and an assistant psychologist and was tape-recorded. Notes were taken during and after each session. Every group followed the same introductory format, which included:

Completion of a short questionnaire requesting demographic information.

Welcome and personal introductions,

Background information to the study.

Outlining of ground rules for the session (e.g. interruptions).

Assurance of confidentiality of the session and recording.

Explaining and distributing a handout on the role of clinical psychologists.

This was followed by a questioning route (with probes as appropriate) which explored:

Participants' previous knowledge and experiences of clinical psychology.

Their general impressions of clinical psychology (gained from others, media, etc.).

Participants' knowledge about how one may access a clinical psychology service.

Participants' feelings about using GPs as the main route of access.

Aspects of a service which would facilitate or deter service use (likes and dislikes).

Preferred locations for a psychological service.

The importance of the racial/ethnic background of the psychologist.

At the end of each group the discussion was summarised from the notes to check that they were an accurate account and participants were asked if they had anything further to add.

Data analysis

Data analysis involved the identification of themes at two levels. In the first level of analysis, responses which related directly to the questions posed by the group facilitators (e.g. the preferred location of a psychological service) were identified. Those responses that occurred in more than one group were privileged. This level of analysis was carried out jointly by both authors. The second level of analysis involved the identification of underlying themes that enabled an understanding of the perspectives of the participants. Themes that emerged in the transcripts of each group were coded and confirmatory or contrary evidence was identified in all the other groups. In this way the debate for and against a particular perspective or opinion was identified. The first author carried out a preliminary identification of underlying themes, and the second author examined the data a second time. All the researchers involved in this study were of African or African-Caribbean descent, and this clearly had an impact on the study in terms of its inception, implementation, data collection, data analysis and interpretation. However, the authors also drew on the existing literature about Black people and mental health in the interpretation of the data.

Participants are numbered for each conversation that is quoted, but these numbers do not identify participants.

RESULTS

During the focus groups, it quickly became evident that the participants knew little about clinical psychology services, how they were provided and how to gain access to them. It was also salutary to note that the differences that were presented by the group facilitators between psychology and psychiatry were new to all participants except two, who had some professional contact with mental health services: ‘You just look at the label and you think psychology, yeah, psychology is psychiatry'. Indeed, for some people it appeared that this differentiation was immaterial, and possibly viewed as irrelevant.

This section presents the themes that were derived from the data, and some initial discussion of the issues at stake. It must be stated from the outset that all these issues are interconnected and the distinctions made between them are artificial and for the purpose of presentation.

Power and control in service use

One of the most prominent themes in the focus group discussions was that of retaining control in engagement with services. This was evident in terms of ensuring confidentiality, and participants in each group voiced concerns about record-keeping, and letters:

“...and so I'd feel uncomfortable with notes because I'd want to know what they're putting.”

“...and it would also put people off if they felt they were going to get things written on their record that, you know, could sort of label them as someone who's been to see a psychologist.”

There was general concern about how the service would use client information and specific fears were raised in two groups concerning 'authorities' gaining control of their children. These fears were stated clearly and amplified in the following interaction between participants in the fourth group:

P1: “... for us to know that it is going to help us and it's not going to hinder us in any way. Like I say, the fact that social services might come and take your child away, or want to lock me up or something like that.”

P2: “So you'd need to be reassured as well by, I don't know, the way that the service is put across, or by whoever it is that you're going to see.”

P1: “And who else is going to get involved when I come and see a clinical psychologist.”

Issues around gaining access to the service were discussed by the participants, especially in terms of access through the GP. Concerns were raised about whether or not this was an appropriate role for a GP:

“...it shouldn't be his job, he's a doctor, he's not a psychologist, is he? To me he deals with patients. He deals with broken legs, swollen arms. To me that's not his problem at all. It shouldn't be his problem at all. That should be in a different section altogether.”

Linked to this concern was a feeling that the GP might offer an unacceptable intervention:

“...what did he give me? Anti-depressants. So I wasn't sleeping, I wasn't this or that. I needed to stop taking them because this was taking control of me ...”

The sense of losing control also applied to the process of referral in which a person goes to the GP with a problem, and is then referred on to someone else:

“I don't think I could go to my GP with something like that because it's, I just, it just escalate more, like where you've got given the antidepressants and then the psychologist and all that kind of stuff.”

Some participants felt that they could discuss psychological and social difficulties with their doctor, but this was because they had built a good relationship over a period of time:

“Yeah. I'd definitely go to him. Yeah. Because I think if you've got a good doctor that you can talk to and you have a good relationship with, then you'd go to him or her for anything, wouldn't you?”

This participant went on to describe how she'd built a positive relationship with her GP, and this led to questions about the appropriateness of having to work at the relationship with the GP and with other health professionals. It was felt that this constituted an additional problem for Black people:

“... That for Black people we have to work at each and every relationship that we enter into, be it with our GP. with our psychologist. with our teachers, with our children's teachers. We have to work at it ... why should we then go and have to go to a psychology service where we have to work at the relationship to help ourselves?”

However, one participant felt that even though they had a good relationship with their GP, it was not appropriate to approach them with concerns about the children. Participants were overwhelmingly in favour of a self-referral system where they could go straight to the person they wanted help from, thereby retaining some control over issues of access and confidentiality, rather than having to go through someone else:

“Because it would be nice if the parents could approach you. rather than take it through the specialist ... it would be nicer for them to ring you, then say can I have an appointment.”

Questions about the importance of the race or ethnicity of the psychologist were raised in most groups even before the facilitators introduced the issue. Discussions revealed a number of themes which informed participants' thinking about this issue. Firstly, and probably most fundamentally, participants argued that there would be an enhanced understanding of their difficulties if their psychologist was Black:

P1: “And not only that. but it's how that person (a White psychologist) is seeing you. You don't know where he's coming from, he doesn't know where you're coming from, you know what I mean? And you're talking and you don't know if they're understanding you, and I'm just thinking you just don't think that they understand you anyway. So there would be no trust, there's nothing there to begin with. there's not a foundation to build on. Whereas, you know, if it was a Black psychologist you know there's going to be a closer understanding.”

P2: “Yeah, 'cos, I'm just thinking, yeah, if you start with a basic cultural understanding. you know, that means there will be a closer understanding.”

There appears to be an acknowledgement that the lack of understanding would work both ways, and the participant may also have difficulties understanding a White psychologist. Parents also felt that having a Black psychologist was important in terms of understanding their children's difficulties:

“cos, you know. it's like social work, you know. social life of a Black person might be a different thing. usually. to a certain extent it might be the same. But to some extent it's different as well, so obviously you've got to have somebody who understands what it feels to be able to communicate, that's why they're classed as difficult. because they can't, you know what I mean? Find a connection with certain things to the children.”

In other words. a lack of understanding can lead to Black children being labelled as difficult.

Other participants raised the issue of language and communication and there was a feeling that these issues are more readily addressed in the Asian communities because of different languages. Services do not consider language and communication issues for the African-Caribbean community because of the assumption that they speak English: “... They probably feel they can communicate with us to a certain extent.” There was concern that this was especially so for some sections of the community who communicate best in patois: “You know, to be understood, 'cos there's a lot of our parents and grandparents who're just not fluent in putting themselves across.” One participant summarised the issue succinctly: “It's the same like, you know, you've got to have a Chinese chef to cook Chinese food!”, to the amusement of the rest of the group.

For some participants, issues of religion were also important, and it was felt that a Black psychologist would have a better understanding of the importance of being a Christian and attending church regularly.

The nature of the problem to be addressed also influenced participants' choice of a Black psychologist. For example, one parent felt that seeing a Black person would be more helpful for a child who was experiencing racism from a White teacher. It was suggested that the child would feel more confident talking to a Black psychologist. Other reasons given for preferring a Black psychologist included the notions of respect and role models: “I think just being respected as a Black person, and your views being respected. That says a lot.” The notion of role models and positive identification was also raised. especially for children.

Some participants felt that issues of gender needed to be taken into account along with racial and cultural issues. Both men and women in two of the groups mentioned the fact that an understanding of gender issues may be facilitated by having a psychologist of the same gender as themselves:

“... Not understanding that you're a woman and understand where I'm coming from. not only because of your colour, but being a woman, being identified in the position that you have ...”

Despite the arguments in favour of a Black psychologist, discussions in all the groups also introduced qualifiers to this choice. For some participants, there were issues of confidentiality and professionalism. As long as the Black psychologist was behaving professionally, he/she would be preferable to a White psychologist:

“But I think a Black person in that field at that level is going to be, you know. is gonna be a professional. so he's obviously gonna keep people’s business confidential.”

Although some participants were aware of some Black professionals who did not adhere strictly to codes of confidentiality, there was also an acknowledgement that not all Black people are the same. A couple of participants said that they would see a White psychologist as long as he/she was aware of Black people's issues:

“...so I think if a White person is aware of Black people's... then really it doesn't matter if it is a White person. I mean personally I'd see them.”

Other concerns about Black psychologists included issues around their training and models of practice. There were discussions in three groups about the nature of clinical psychology training and its adherence to White middle-class and Eurocentric values. Some participants had studied psychology and felt that most of it was irrelevant and therefore harmful to Black people:

“...you been trained in White Eurocentric ways, and you're going to he used to mess up a Black person...”

The argument was elaborated further and it was suggested that, as the service was run by White people, Black psychologists have to work within White frameworks that are standardised across the service. Throughout this debate. issues of power and control were evident with regard to the real meaning of choosing a Black psychologist when White people are still “...pulling the strings...”. Some participants also felt that Black people who ‘go through the system' are difficult to relate to. They raised issues of internalised racism that may exist when Black people feel they have to reject anything Black in order to get ahead. One participant argued that this was more evident in the 1970s, and that more recently, Black people who go to university come back to their communities and get involved.

Discussion about the preferred location of the service also had implications for power and control. There were opinions that it should be located somewhere that preserved confidentiality and was comfortable. It should also he somewhere that was familiar to the person.

“Yeah maybe a youth club or something like that, because I know that I'm going there. The people there are on my kind of wavelength ... You know, it's set up for me, so I'd be comfortable, away from all that medical clinical stuff.”

Many felt that a health centre or community centre (especially one that serves the Black community) would be best as they are places that offer a range of other services and facilities. Other suggestions included a health shop, workplace and college. For some participants, being seen at home would be preferable unless the problem was based there (e.g. marital conflict).

There was a lot of stigma associated with the use of psychological services and the fear of being labelled:

“It can be a dangerous thing in the sense that this child's been labelled now and throughout his life, through school, this will follow him.”

These concerns were, to some extent, due to services being associated with psychiatry or with negative experiences of psychiatric services:

“It's just the stigma that if you see a psychologist and a lot of people don’t understand the difference, think that you're seeing a psychiatrist, and you're automatically labelled as schizophrenic.”

This concern was also related to record-keeping and files. It was felt that Black people already had enough to contend with without being further burdened with a record of having mental health problems.

Many participants felt that the location of the service was important in terms of reducing potential stigma:

“But I think a health centre could be a good idea because if it would become as accessible as going to the doctors then the stigma would go eventually, wouldn’t it?”

Additionally it was felt that establishing links with local Black communities and publicising the service through Black networks (such as churches and community centres) would help to reduce the stigma:

“I think to take the stigma off as well you have to publicise yourselves and coma across as acceptable ... some of the Black radio programmes ... you can say there is this service for children and so on ...”

During the course of the focus groups, participants recounted their own (and acquaintances') experiences of oppressive practices in education and other systems. Stories were told about the experiences of Black people in the criminal justice and psychiatric systems:

“...you hear of certain things, you've heard of a situation that happened to the man that was in prison and he was beaten up, and he died in prison, and then his parents took the situation further to find that he was given some drugs, I believe, and he was given too much of a dose or something like that ...”

There was recognition of the fact that Black men are more likely to be controlled using physical means:

P1: “So you think (in terms of psychology services) of people giving drugs to people in mental hospitals?”

P2: “Yeah. Probably purposely . . . perhaps because he's Black, because he's big, because he's strong, we have to calm him down ...”

Some parents gave examples of schools carrying out investigations of abuse without their knowledge or permission, whilst others talked about the ways in which the education system undermined their role as parents by not informing them about their child's progress.

Impact of migration

Through the conversations in the groups it became clear that many of the participants were second-generation African-Caribbean whose parents had migrated to the UK. Although they arrived here as children, participants talked about the differences in the ways that people sought help and under what circumstances. In one group, a participant talked about her understanding that, in the Caribbean, marriage problems were taken to the oldest married couple, and physical problems to the ‘obeah man'. This is accepted as being in-house' as opposed to the Westernised' idea of talking openly' about your problems:

“... in yard if you had problems if it was marriage you went to the oldest married couple, if it was doctor, you'd go to the obeah man or what have you. You know what I mean? But it seems to be in-house where here we're taught Westernised, if that's the right word, we talk openly, you know, within reason, but our own Black people used to share it in-house, you know, like if there's a problem that needs assistance they wouldn't call the police, they would deal with it themselves.”

The idea of keeping problems 'in-house' does not appear to be very clear in terms of the boundaries of the 'house'. Another participant later in the conversation suggests that the older generation would not use psychology services because they are an aspect of 'White man's medicine'.

P1: “... I don't think it's the fact that they mind it's a stranger. I think it's more of the fact that you know it's a case of you know. psychology, medicine, prescriptions, you know.”

P2: “White man's medicine.”

This suggests that the boundaries, for some participants, are possibly between the Black and White communities, rather than between one family and the next. It is also possible that the concept of 'in-house' has been modified by migration, and the boundaries re-drawn on a cultural and racial basis.

In one part of the group interviews, participants were asked if there was a time when they could have used psychological services. Some participants identified the difficulties they experienced on arriving in this country as children. Common experiences of racism and cultural isolation were described, but also the fact that these issues could not be shared with parents and other adults in the community because adults had their own problems and were totally unaware of the issues that Black children were facing in school. Participants agreed that a result of this situation was that the children got together to support each other. They talked about the problems and reminisced about their lives back home' in the Caribbean.

Rather than anything else, because I don't think our parents were a lot of help, because they had to deal with other stuff here and a child coming here and all that, you know, erm, so I think we dealt with it together. and just used to talk about the way that we, what we knew from back home, and what things are like here. I don't really know how we coped with it.

However, in the conversation, there is also a sense that coping with the uprooting effects of migration along with the racism was actually too much for them as children. The support they received from each other was a comfort rather than a solution to their difficulties. Some went on to say that they were sure that some people in the community were still suffering the effects of this experience. The difference between their own generation and the next was also remarked upon:

“...cos I mean the generation that are coming up now. you know, they're not going to put up with a lot of the things that maybe my Dad and maybe I, well my generation. put up with. I think they start to demand more and they'll find ways of, you know, getting what is rightfully theirs, as just, you know, human beings.”

Community self-reliance

The extent to which participants relied on family and community resources in times of trouble was debated in all the focus groups. Some people spoke about personal preferences whilst others argued from their observations of what has happened and is happening in the Black community. There was no clear consensus as to who was included in the Black community, but there were debates as to whether people of Asian descent and people of mixed parentage could or should be referred to as 'Black'.

Relying on family and friends was seen as a cultural characteristic by some participants.

“Well I think what we Black people tend to do is to talk to each other. You support each other, that's what you do. You don't go to the professionals. You don't find them running to psychiatrists - but the problems are there and people are being helped in a small way by talking to each other. You'd be surprised.”

In a number of instances. participants identified themselves as relying on family and friends. but felt that there were others who might need the help of professional agencies or more objective help:

P1: “. . . if I've got social problems. or like if I've got a problem in relationships. I'm not looking to psychologists. I'm looking to friends or family. you know. or people who know me”

P2: “... I hear what you're saying, but you see there's some people who don't have that kind of relationship to talk to somebody about their problems. They need somebody objective to talk about it with.”

The size of the Black community was raised on a couple of occasions in relation to community self-reliance. There was some concern that confidentiality and objectivity could be compromised as the community is so small that everyone knows everyone else. This was one of the few instances when participants would consider choosing a White psychologist, as discussed above:

“... but on the opposite side of the coin, perhaps seeing a White psychologist could be better for a particular individual because going to a Black person because there's a matter of identification, perhaps you might feel that they're going to be judgemental. At the end of the day, the Black community is very small.

Confidentiality. You can never he sure how confidential it's gonna be when you talk to someone you know like in the Black community, it's more than likely everybody knows everybody else kind of thing.”

Another aspect of community self-reliance, which was distinct from relying on friends and family, was the idea of the wider Black community becoming self-reliant in terms of not needing to go to White services for help. This was partly due to issues of racism and not having to expose oneself or other family members to a hostile environment, but also due to questions about the appropriateness of using services which are by and for White people.

“...I study as well and whoever else has studied psychology we know that they don't study, well, I've not seen anything to say that they've studied Black people. How can I relate to that? How can I trust a service that has never studied Black people? ... Why should I go to a White psychologist to help me with my problems when they don't understand me. You know what I mean?”

Another participant in the same conversation went on to clarify her view that the race of the psychologist is irrelevant if the knowledge and practice base is the same:

“Well then again even whether it's a White psychologist or a Black psychologist, at the end of the day they've studied the same theories, the same applications. So even if you're going talking to a Black psychologist, they may be able to relate on a personal level to some degree, but the application of the knowledge, of psychology, is going to be defined and therefore confined by White perspectives.”

The idea of self-sufficiency and having the resources to run our own affairs was a potent one in most of the groups. One group talked about being capable of taking care of things 'on our own', and having some control. Issues of funding were raised with some bitterness about the way in which funding for resources for the Black community is often piecemeal and short-term. In fact, one participant challenged the aims of the study and felt that it would only result in having to approach White organisations with a ‘begging bowl'.

P1: “What would attract me is the idea of us being capable on our own. you know, that aspect of it. Just that idea.”

P2: “Having some control as well.”

However, there were also people in the groups who felt that Black people have a right to expect the services to meet their needs:

“... so we should he going to professionals and saying we need help as well and then they can see that we’re not meeting these people's needs, but if we keep it to ourselves, they're never going to know that there is a problem, so I think we should tell them that we've got a right to this service and we've got a right to be represented as well.”

Parenting

Participants talked about their role as parents and how they had attempted to help their children navigate the system and prepare them for the future. They were painfully aware of the problems that their children were facing in school and the issues around school exclusions and the labelling of Black boys as difficult:

“...I'm fed up of hearing so many Black kids have been expelled from school ... because I always think maybe that's what they want, the Black boys who supposed to be the breadwinner of the future, the supporter for the family. They want them to fail, they want them to be suppressed, they want them to end up in prison, but if you look at the last 5 or 10 years, quite a lot of children are going to university, maybe more girls than boys, but they are getting through.”

Parents felt an additional responsibility to act as advocates and protectors for their children in terms of their ethnicity and racism. They have to understand the system, and whilst not trusting it, try to get the best for their children.

Parents discussed the importance of their children receiving education from a Black perspective. They felt that children need to be taught about Black history and the achievements of Black people within the school curriculum. This was seen as crucial for psychological health and a sense of belonging:

“... but not many people are aware that Black people have ever invented anything or contributed anything to society. So I think, you know, they need to maybe target the people who can really help to bring about a change of attitude maybe in the school curriculum to say, you know, Black kids and Black people are a part of society whether you want to accept it or whether you like it or not. It's important if they're going to make a contribution, a positive contribution, that they're aware that Black people have achieved and can achieve.”

Having Black role models was also seen as important. Participants felt that this was needed to counteract negative portrayals of Black people.

P1: “... that we're always seen to be down and dirty.”

P2: “Hopeless victims waiting for White people to help us out.”

P3: “Then the kids - they don't really want to relate to it.”

There was concern that Black children would reject the Black community if this was the dominant portrayal. Parents also expressed a preference for their children to see a Black psychologist for reasons of positive identification and role modelling:

“I think it's just fundamental identification in all areas, whether it's social, culture or we share the same history, or whatever, it's just a matter of identification, especially for children I think. 'cos I mean older people, we can intellectualise it to a certain extent, whether it's being seen by a Black or White psychologist, hut for a child with problems to see somebody who initially looks like them ...”

Some parents had taken their children to Saturday School in order to provide the positive identification and teaching about Black history that is missing in mainstream education:

“... that's why I like Saturday School, because my child can go and see a Black person.

Parents in one group talked a lot about how they help their children cope with problems. One father talked about the way that he tries to help his sons if he realises that they are upset about something. He described spending time with them in activities that they enjoy rather than trying to get them to talk:

“... so getting involved with them actually teaches you about your child... keeping away from them and then they go to school and come home to me problems cannot be solved that way because ... you're not involved.”

Other parents agreed with the importance of spending time with children, and how this built the foundation for a strong relationship in the future. They felt that this would prevent problems developing and allow them to deal with any issues earlier rather than later. They discussed the fact that this way of parenting was totally different from the way in which they were brought up in the 'West Indies', where relationships with parents were much more formal, and corporal punishment was used regularly. Their roles as parents meant that they had to teach children values, such as working for things in order to properly appreciate them and the importance of good manners, even though these messages were undermined by society. One parent felt that Black children generally do not benefit from the countryside. He had taken his children on walks in the countryside since they were infants and he felt that this had a positive effect on their development:

“... this afternoon, take him from school, go down to the woods, down to the lake and it might be six times a year or 10 times a year, but to me it's important, and they enjoy it. I mean if I go out to the woods there's no Black kid in the wood. There's no Black parents out there. Why? Where are they? ... The kids need to go out. They need to experience, hopefully to benefit from the atmosphere. yeah? Black kids aren't getting it.”

DISCUSSION

The conversations in these focus groups show that issues of power and control are fundamental to Black people's experiences and expectations of mental health services. These issues are evident in the amount of control that can be exercised over confidentiality, access, location and the ethnicity and gender of the psychologist. Although these issues may also be pertinent for White communities, parents raised additional considerations of racism and the over-representation of Black people in the country's psychiatric and penal institutions. These institutions are seen as instruments that are used by the state to disable and disempower Black men. It is important to acknowledge the strength of feeling which was expressed about issues of power and control by several participants.

One of the backdrops for this issue is the large-scale migration of African-Caribbean people to this country which took place earlier this century. The interplay between this uprooting and experiences of racism has led to different experiences for different generations. The participants talked about how their parents were unaware of their experiences and were unavailable for support. These issues were also documented in the BBC's Windrush season (Phillips and Phillips. 1998. p. 301) with examples of how parents who migrated here trusted the authorities and believed that their children were bad. Parents of Black children are in an intolerable position. They have to make their children feel valued in a world that continually devalues Black children's experiences and contributions, and at best places them in the position of 'other' or exotic. at worst labels them as deviant (social exclusions) and dangerous (incarceration). They have to consider the safety and future of the children in any encounter with state institutions, and be able to act as advocate and protector.

Rogers et al. (1997) identified community activism as one of the dimensions of empowerment in mental health services. The 'community' for these African-Caribbean parents is specifically the Black community. An analysis of the importance of community activism has to incorporate the idea of community empowerment. Being a member of a disempowered community has implications for how empowered an individual member can feel in the face of institutionalised racism. A columnist in a leading Black newspaper recently wrote about his experiences when he received his PhD and put the title 'Dr' on his credit card. On one occasion, a ticket clerk accused him of forgery and insisted on getting the card checked. Rather than according him respect, this individual achievement resulted in accusations of criminality (Sewell. 1998). As Sassoon and Lindow (1995) state, with regard to the user movement: The fact that different groups of people are accorded varying amounts of power depending on their race, culture and class has far-reaching implications for potential involvement'. One neglected dimension of empowerment would seem to be knowledge. This can operate on many levels, and it appears that whilst the White media continues with negative or stereotyped images of Black people, the Black media has become a source of knowledge for many Black people about issues affecting the community. Papers like the Caribbean Times. The Journal and The Voice regularly carry reports of deaths in custody, racist policing and exclusions of Black pupils. These stories are either not reported in the White media until some weeks later, or not mentioned at all. The importance of knowledge that promotes self-efficacy for Black communities cannot be exaggerated.

Within mental health services, little is said and even less is written about the application of Eurocentric theories and practices in work with ethnic minority people. It sometimes seems as if, as mental health workers, we would rather carry on in the conviction that we know best, even when it should be obvious that we know very little. Services aim to reach more people, disempowering them with alien theories and ideas rather than ensuring that they develop their own voices and solutions. Within the USA, attempts are being made to construct theories and perspectives of psychological health which rely on African and Asian knowledge bases (Akbar. 1984: Schiele, 1994). The success of these endeavours in terms of service provision have yet to be evaluated, and may not be applicable to Black British populations, but they provide some support for the possibility of non- or less-Eurocentric mental health services.

A major flaw of this study is the apparent sampling bias. The proportion of parents in professional and managerial jobs is higher than one would expect. and suggests that the methodology was less appropriate for the unemployed and those in lower occupational classes. It is difficult to identify the reason for the bias. and it is likely that some parents were so suspicious of the aims of the groups that they opted out. Other limitations of the study include the fact that the focus was on service provision. rather than alternatives to mainstream services or preventative ideas. Further studies which explore perceptions of the factors that affect mental health, and which recruit participants who have had some experience of the mental health system are essential. The results of this study were used in a bid for the funding of a post for a Black clinical psychologist who will develop services for African-Caribbean families. This bid has been successful, and should lead to the development of an appropriate and accessible service for African-Caribbean families in the city. In addition, the first author has been able to transfer some of the principles and lessons into a new post developing services for ethnic minority families in another city.

Most participants in this study made it clear that an appropriate service would have to offer confidentiality, self-referral, a non-stigmatising environment and access to Black psychologists who are able to practise from a non-Eurocentral knowledge base. They also felt that the service should be linked to the Black community and preferably based within it. Some participants said they would be willing to see a White psychologist who had a clear understanding of the issues which affect Black people, thus suggesting that choice is an important consideration. Research in the USA has found that service costs can be reduced through ethnic matching (Jerrell, 1995; Snowden et al., 1995) and it seems timely to begin to address this issue in this country. There is a sense that times are changing and that younger generations are not prepared to put up with things in the way that their parents did (Hutchinson and Gilvarry, 1998). In order to listen to what people have to say and support their needs, it seems that services have to learn to relinquish power. We have to learn to meet people where they feel comfortable rather than where we feel comfortable, we have to be able to privilege their explanations of their distress rather than our own, we have to be accessible and respect people's choices. The findings of this study add the thoughts, views and opinions of members of the African-Caribbean community to the weight of evidence accumulated by authors and researchers over the last two decades.

ACKNOWLEDGEMENTS

We wish to express our gratitude to the African-Caribbean parents who participated in this study. We would like to thank Julia Faulconbridge for both personal and professional support during this study and in the development of services for ethnic minority families in Nottingham.

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