Clinical ethnography in severe mental illness: a clinical method to tackle social determinants and structural racism in personalised care

Abstract

Ethnic inequalities in the experiences and outcomes of severe mental illness are well established. These include a higher incidence of severe mental illnesses (psychoses), adverse pathways into and through care, including crisis care, police and criminal justice systems involvement, and care under the powers of the Mental Health Act. The situation persists despite awareness and is driven by a mixture of the social determinants of poor health, societal disadvantage and structural racism, as well as conflictual interactions with care systems, which themselves are configured in ways that sustain or deepen these inequalities. Although training and education are often proposed, this is not shown to have sustained effects. Clinical processes (interviewing/assessment/formulation/intervention) need to address systemic influences and improve the cultural precision with which care is delivered, organised and commissioned. We discuss clinical ethnography and present evidence of its value in addressing systemic as well as individual care needs for diverse communities.

A Refugee Rose of competencies and capabilities for mental healthcare of refugees

“…Thus clinical ethnography is a tool for assessment and understanding, and necessarily slows down this process to encourage careful reflection; it addresses not only the individual embodied experience of distress, but also the social nexus within which it arises, the beliefs and vocabularies of the patient and her kinship system, and the intersectional and social positionality of the person seeking help and the clinician. 31 , 32 Ethnography and cultural consultation methods can also interrogate organisational practices that are institutionalised and unnoticed, 33 , 34 yet these can give rise to the neglect of racism and the complex needs of marginalised groups; the risk is that such practices are silent on the coercive and criminalising responses from the state and institutions, when these interact with vulnerable populations. 33 , 35 For example, if racism is part of the lived experience of those seeking help, and clinicians do not recognise it or ask about it, this reinforces a lack of connection with the patient and can lead to alienation and isolation.…”

Identifying effective characteristics of behavioral weight management interventions for people with serious mental illness: A systematic review with a qualitative comparative analysis

“…However, more exploratory research may first be needed to understand how or why interventions are more or less likely to work for people with SMI including different ethnic groups. This should include novel approaches to evaluation, for example, using ethnographic methods or those recommended under the person‐based approach, 95 , 96 which would allow an understanding of the context of users and their views of particular characteristics of an intervention to guide trial development. Similarly adjunctive approaches include realist synthesizes to identify underlying causal mechanisms of behavior change.…”

A meta-ethnography investigating relational influences on mental health and cancer-related health care interventions for racially minoritised people in the UK

“…The problems that racially minoritised people (i.e. people “actively minoritised by others rather than naturally existing as a minority” [ 1 ] (p. e419)) associate with health care—like stigma, discrimination and unempathic treatment—are well documented [ 2 , 3 ]. However, professional health care training appears not to readily assuage these problems.…”

“…In response, some researchers have called for deeper ways of thinking through the issues involved. For example, a kind of ethnographic approach to clinical care, whereby practitioners are encouraged to enter into the worlds of racially minoritised people with the curiosity of anthropologists, was suggested by one group of scholars [ 2 ]. Nevertheless, it is clear that better ways of conceptualising racially minoritised health care are needed.…”