The RCPsych Article of the Month for September is ‘Gypsy, Roma and Traveller populations and mental health in the UK: a need for real working together and co-production of services‘, written by authors Derek Tracy, Amy Ward and Radha Kothari. The paper is published in BJPsych International.

There has been a rightful focus on equity in healthcare systems, and drives to co-produce services in a culturally informed manner with those who use them. In my experience, this has not been equal in approach, and a group, or groups of people, who remain particularly excluded are Gypsy, Roma, and Traveller (GRT) communities. The term GRT is commonly used, though not accepted by all: nevertheless, I will adopt it here, not least to highlight the heterogeneity of cultures that can be very different under this umbrella term.

An initial problem is that our data on GRT communities and mental health services are limited: this might be a recording issue, including stigma at the very point of contact. But what information we do have shows that interfaces are often at points of crisis with communities who have far greater-than-average rates of mental illness, substance use, self-harm, and of completed suicide. When contact does occur, healthcare workers have been shown to harbour many of the prejudices and biases of the rest of the general population, which can manifest with a real failure to have any desire to outreach to, or understand, GRT communities.

Research and reports have shown that there can be internalised challenges for some from GRT backgrounds, both in terms of stigma surrounding mental illness, but also arising from adverse experiences with institutions. The result can be a bidirectional lack of trust.

In our linked paper, which was co-authored with a member of the Irish Traveller community and a Clinical Psychologist who works with individuals from GRT backgrounds in a prison setting, we put forward proposals to move this issue forward. The first is acknowledging the problem, including that the aforementioned crisis-interfaces likely reinforce staff prejudice and patient lack of trust. As with other forms of culturally informed practice, we need to reach out with humility and ask for assistance in effecting change trying to change structural power-imbalances. Relationships need to be grown, and consideration given to trauma-informed approaches to interventions from pregnancy through adulthood into later life: just like we do – or should do – for everyone else.

However, to effect meaningful change, we need to redress the professional and organisational biases inherent in our healthcare systems. There is a seemingly lack of people from GRT backgrounds in positions of authority, or with representation, across most national agencies, though I note that data from the Traveller Movement indicate that a large majority have hidden their ethnicity to avoid discrimination.

The needle has not moved in terms of health outcomes in recent times, and there are dangers both of ‘othering’ GRT communities in terms of only seeing them through a ‘deficit lens’, and of just repeating measurements of inequity without effecting any real change. I would conclude where I started, by re-emphasising how the ‘GRT’ label masks very different groups of people, with often quite varying needs. There are inherent risks of simplification and saying what people from ‘GRT groups’ need, missing this complexity.

Gypsy, Roma and Traveller (GRT) communities, an umbrella term used for heterogeneous groups with nomadic tradition, are facing worse mental health outcomes than the general population and many other ethnic minority groups. In their informative and interesting paper, the authors discuss the needs of these diverse and culturally rich communities and barriers in them accessing effective mental healthcare. Stigma, substandard cultural understanding, and lack of initiatives aiming at coproduction of services with these groups, lead to poor engagement and contact mostly during crises which perpetuate this concerning pattern. Raising the profile of GRT issues, engaging GRT communities in the development of culturally informed integrated services with focus on prevention and early intervention, education of professionals and work on their biases, building trusting relationships, and having GRT-led conversations may be the starting points in helping to redress imbalances in GRT mental healthcare access.

Marinos Kyriakopoulos
Editor-in-Chief, BJPsych International