Provision of services for the African—Caribbean mentally ill population has become an increasing topical area of interest in British psychiatry. Primarily, this is because it has been reported that this group is dissatisfied with the psychiatric services provided by the traditional mainstream routes (Reference Koffman, Fulop and PashleyKoffman et al, 1997 ; Reference Parkman, Davies and LeeseParkman et al, 1997 ; Reference Hutchinson and GilvarryHutchinson & Gilvarry, 1998). This dissatisfaction seems to develop over time as it is not evident at initial contact with services (Reference Leavey, King and ColeLeavey et al, 1997 ; Reference Burnett, Mallett and BhugraBurnett et al, 1999).
When this is seen in the context of the high rates of psychotic illness reported for this group (Reference Thomas, Stone and OsbornThomas et al, 1993 ; Reference Bhugra, Leff and MallettBhugra et al, 1997), this problem takes on an even greater significance. In addition, the socio-economic resources of this group are relatively limited when compared with the rest of the British population - this is compounded by the experience of racism (Reference NazrooNazroo, 1997). One of the attempts to address this situation has been the establishment of voluntary sector organisations which have attempted to provide more culturally appropriate mental health support services. The Fanon Project was one of the first of these.
The Fanon Project was initiated in Lambeth after the recommendation of the Scarman Report (commissioned in the aftermath of the Brixton riots ; Reference ScarmanScarman, 1981), by a group of social workers and community activists. It was designed to serve young Black men who were being seen on the streets of Brixton and were either known or suspected to have a mental illness (Reference MoodleyMoodley, 1987). Initially funded and set up by the Brixton Council, it was opened in March 1985 and was eventually named after the Martiniquan psychiatrist, Frantz Fanon, whose work dealt with the impact of racial identity on psychological distress in colonial societies.
The Brixton Community Day Centre (Shore Centre) is run by the South London and Maudsley Trust and therefore provides a natural geographical point of comparison with the Fanon Day Centre (FDC). The Shore Centre is fully integrated within the Trust's organisation and deals with patients referred from two Lambeth mental health teams. It provides a range of social, occupational and medical treatments and is located near to the centre of Brixton (as is the FDC).
Very little research has been conducted into the work that is done by the voluntary sector within mental health. This study sought to identify and characterise the service users who attended the Fanon project and compare them with those who attended a day centre operated by the mainstream psychiatric service in the same catchment area.
The study
The subjects consisted of those people who attended the FDC over a six-month period. The FDC was initially set up to see male service users only, but now also sees female service users at a different site. However, we decided to concentrate on the male group. A group of age-matched male service users were recruited from the Shore Centre. These two groups were assessed by interviews with the service, interviews with their keyworkers where possible and review of their case notes. Reasons for, and frequency of attendance were obtained along with details of contact with other health and social support agencies. Forensic histories were also obtained.
Demographic information on marital status, housing, employment and nationality were also obtained by interview. The subjects were then assessed for social functioning using the Global Assessment of Function (GAF) which is derived from the Global Assessment Scales for Symptoms and Disability (Reference Endicott, Spitzer and FleissEndicott et al, 1976). A qualitative assessment of met and unmet needs at the time of interview was undertaken using the Camberwell Assessment of Need (CAN) which has been shown to differentiate between staff and service user perceptions of needs (Reference Slade, Phelan and ThornicroftSlade et al, 1999). Care was taken to exclude those patients who attended both services.
Demographic characteristics were compared between patient groups using χ2 tests for categorical variables and analysis of variance (ANOVA) for continuous variables. For continuous outcomes, means and standard deviations summarise the data in each group while for the categorical variables, proportions of subjects in each group with the particular characteristic are reported.
Results
Demographics
A total of 54 male service users were interviewed at the FDC, the age range was 22-58 years with a mean of 37.6 (s.d.=3.7). This comprised 60% of those registered with the centre. At the Shore Centre 53 service users were interviewed. The age range was 20-61 years with a mean of 35.8 (s.d.=5.1). A summary of the demographic characteristics are given in Table 1. Most of the FDC service users (n=47) were of Jamaican origin (n=24, first generation ; n=22, second generation ; and n=1, third generation). The other seven service users came from other islands in the Caribbean (n=3, first generation ; n=1, second generation) and Africa (n=2 from West Africa ; n=1 from Eritrea). Island of origin data was not collected for the statutory sample, but 29 (55%) were of Caribbean origin.
Demographic profile of service users
| Fanon Day Centre | Shore Centre | Significance | |
|---|---|---|---|
| Mean age (years) | 37.6 | 35.8 | |
| Frequency of attendance (weekly/monthly) | 38/16 | 38/15 | |
| Number unemployed (%) | 54 (100) | 42 (79) | P<0.01 |
| Caribbean origin (%) | 51 (94) | 29 (55) | P<0.002 |
| General practitioner registration (%) | 20 (54) | 52 (98) | P<0.0000 |
| Forensic history | 41 (76) | 13 (25) | P<0.001 |
Employment history
All of the FDC service users were currently unemployed (100%) while only four were known to have been employed at some point in their lives (7.4%). These figures compare with 80% unemployment rate in the statutory sample and a lifetime employment rate of 30%.
Forensic history
FDC service users had significantly more forensic histories than their Shore Centre counterparts (Table 1). Of the 41 (76%) service users from FDC who had positive forensic histories, only five had been convicted or charged with violent crimes such as grievous bodily harm or shooting. Only 13 (25%) of the statutory service users had forensic histories.
Attendance
With regard to frequency of attendance, some of the FDC service users attended every day (46%). Among the Shore Centre service users, 23% attended up to three times per week. This was due to the nature of the schedules at the respective centres. At the FDC service users can drop in at any time provided the centre is open whereas the schedule is somewhat more structured at the Shore Centre to coincide with specific group activities. For the FDC service users, their main reason for attending was to escape what they described as the ‘system’ as represented by the police and the psychiatric services. At the Shore Centre reasons for attending were mainly because of their doctor's advice and for some activity to occupy their time.
Contact with services
Thirty-four FDC service users were in current and fairly regular contact with the statutory services and had assigned care workers. Another 10 (18.5%) attended other day centres or were known to social services. Two service users visited their general practitioner (GP) for physical ailments and eight denied any current contact with any statutory health or social service. Only 20 (37%) were registered with GPs. This low level of registration with GPs among the FDC service users is significant as 47 (91%) of the Shore Centre service users were registered (Table 1).
Medication history
Forty-nine service users had been prescribed psychiatric medication at some point in their lives, but only 23 claimed that they had ever taken any of the medication (Table 2). All of the statutory sample had been prescribed medication and 93% claimed to adhere to their medication.
Medication history, Global Assessment of Functioning (Reference Endicott, Spitzer and FleissEndicott et al, 1976) (GAF) and Camberwell Assessment of Need (Reference Slade, Phelan and ThornicroftSlade et al, 1999) (CAN)
| Fanon Day Centre | Shore Centre | Significance | |
|---|---|---|---|
| Lifetime prescription | 49 (91%) | 53 (100%) | |
| Adherence (verbal) | 23 (43%) | 49 (92%) | P<0.002 |
| GAF score : Severe impairment | 41 (76%) | 21 (40%) | P<0.004 |
| CAN (main unmet needs) | |||
| Numeracy/literacy | 33 (61%) | 5 (9%) | P<0.0002 |
| Intimate relationships | 29 (54%) | 26 (49%) | |
| Use of drugs (cocaine/alcohol) | 18 (33%) | 8 (15%) | |
| Psychotic symptoms | 23 (43%) | 11 (21%) | P<0.03 |
| Daytime activities | 15 (28%) | 27 (51%) |
GAF
The FDC service users had significantly more severe impairment than those attending the Shore Centre (Table 2).
CAN
The major unmet needs identified for the FDC service users were : (a) the lack of numeracy and literacy skills ; (b) intimate relationships ; (c) use of cocaine and alcohol ; and (d) dealing with psychotic symptoms and the accompanying psychological distress. Daytime activities and problems with intimate relationships were most expressed as unmet needs by the Shore Centre service users (Table 2).
Discussion
The original mandate of the Fanon organisation was to provide a viable, non-institutional alternative to homelessness and street living for predominantly Black male service users with a mental illness in Brixton (Reference MoodleyMoodley, 1987). The service evolved to include the provision of basic social support such as advice on housing (where the Fanon Project had a permanent staff member delegated to deal with the housing needs of the service users) and benefits. It could also act as an advocate for the rights of these patients in their interactions with the statutory health and social services (Fanon Trust, 1995). Our findings here suggest that the patient group attending the FDC are severely impaired and they are likely to place significant demands on the staff. They are more likely to be unemployed and have forensic histories when compared with the attenders at the Shore Centre. High levels of unemployment are associated with the high rates of psychotic illness in the Caribbean population in Britain (Reference Bhugra, Leff and MallettBhugra et al, 1997) and also with compulsory admission (Reference Burnett, Mallett and BhugraBurnett et al, 1999). Their level of contact with other services seems less than optimal and this may reflect a general distancing from institutional structures in Britain giving rise to further material deprivation.
At the FDC, the predominant cultural group is Jamaican and this group may have specific cultural needs which are catered for in the areas of food, social and recreational activities. There may be a need for culturally sensitive and specific services that can make these distinctions in practice. This preponderance may also reflect the census composition of the Caribbean population in Brixton (Office of Population Censuses and Surveys, 1991) but does suggest that in the establishment of these services, care must be taken to understand the needs of the people they are likely to serve.
The number of unmet needs particularly for the FDC service users underlines their level of social and material deprivation. Problems with the development of intimate relationships would appear to be common to both groups and the need for daytime activities is also present. This is an often forgotten consequence of having a chronic, stigmatising mental illness. In addition, the FDC group identified numeracy and literacy skills as being absent and needed, but this may be related to their experience in the school system in Britain or to the disruption of their education arising out of their migration to Britain in childhood. This may also have contributed to their low levels of employment. They are likely to be unemployable when these problems with literacy are seen in conjunction with their mental health problems and their contact with forensic services. Specific rehabilitation strategies are therefore necessary to address these problems.
Another feature which distinguished the FDC group was the distress occasioned by their psychotic symptoms. This is likely to have resulted from their relatively limited contact with the statutory services and a low rate of registration with GPs. It may also be related to their problems with the use of alcohol and cocaine. There may need to be a strengthening of the clinical relationship if this need is to be addressed.
The large number of FDC patients with forensic histories also suggests that this is an area that needs specific attention, particularly since the majority of patients had criminal records for relatively minor crimes. Again, closer links with the forensic and probation services may both serve to pick up cases earlier and to prevent further contact with these services.
The significant level of disadvantage being experienced by the FDC service users illustrates that the voluntary sector has an important role to play in the administration of mental health care to the community, as there will always be some groups who view the institutional services with distrust because of their own experience or that of other members in their community.
The group seen by voluntary services is likely to be much more disadvantaged and socially deprived than the corresponding statutory service and therefore parallels cannot be easily drawn between the two services, especially in the areas of funding and staff utilisation. These voluntary services require extensive support to cope with the difficult problems experienced by their service user group and collaborative efforts must be intensified to facilitate this.
Acknowledgements
We thank Patience Mabena, Peter Hall and other members of the Fanon staff (past and present) for their assistance in this study.
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