Reviews of Hári Sewell's book
"Working with Ethnicity Race and Culture in Mental Health:
A Handbook for Practitioners"

Dramatherapy (vol 32, Spring 2010)

Reviewed by Mandy Carr

'This is a book for practitioners – essentially a self-training book but also one that could be used as a source of knowledge in a complex and controversial field. The author knows about the realities at the grassroots, how NHS mental health care is currently set up, what types of approach are practicable and what are not, and more than all that he understands what busy practitioners may look for in a book called a "handbook".' (p. 12) Thus notes Dr Sunan Fernando, of the European Centre for Migration and Social, Care, University of Kent, in the foreword. This book is full of practical guidance, aiming to improve the quality of work and relationships of mental health practitioners with black and minority ethnic (BME) service users.

This is an accessibly written manual, whose clear structure and subject index make it easy to negotiate. It asks key questions which are reflected by its first two chapter heading: 'What is "Ethnicity, Race and Culture"?' and 'Why are Ethnicity, Race and Culture Important in Mental Health Services?' Further chapters go on to explore quality assessments, recovery-focused care planning, quality relationships in the delivery of care plans, ethnicity in the context of other identities, the roles of the team manager and of training education learning and development. Finally, it considers alternatives to the illness models and explores positive examples of doing it differently. Each chapter is broken down into simple sub-headings. The handbook is punctuated by practical, clearly described training exercises, case studies and evidence, which appear in boxes within each chapter.

Sewell artfully articulates the complexities of issues about race, culture and ethnicity within Mental Health, in accessible language. He uses the prevailing evidence and literature to argue that certain BME groups are overrepresented in the Mental Health services and that it is essential to take action to address inequality: 'If no specific steps are taken to prevent negative patterns the default position is likely to be continued inequality.' (p.39) He gives a brilliantly clear explanation of institutional racism in which he attacks the unhelpful, perhaps 'politically correct', absolutist language of the seventies which polarised debate, leading individuals to feel stifled and unable to even discuss these important issues for fear of censure or causing offence.

Sewell explores the Toxic Interaction Theory, which views the problem as being neither in the minority group, nor in the behaviour of the majority, but in the interaction between both. He looks at practical ways of making positive changes to this interaction. He openly and succinctly explores why it is so difficult for society and organisations to talk about race and culture, gives clear examples and exercises in how to overcome personal fears, including the kind of language that may be helpful rather than 'correct'. For example, he lists complications that practitioners may face when taking account of ethnicity, race and culture which include 'fear that they may end up being a trigger for making race an issue when it wasn't one and worry about a white backlash if their engagement with race leads to tailored (or "special") provision for BME service users'. He also explores the process of workers who do not take these issues into account who may feel 'ill-equipped' or 'that there are no services available to meet the needs that they may identify'. (p. 40)

He aims and succeeds in supporting practitioners and users in finding useful ways of voicing these challenging issues. He directly addresses key questions such as 'When is it safe for workers to talk about things that are stereotypes and taboos?' (p.62) His practical and thoughtful exercises could be effectively used by supervisors, training organisations or in the workplace. Exercises designed to prompt workers into honest internal dialogue, could transform practice. His guidelines for using language which helps practitioners and users to collaborate in finding ways forward are very helpful. For instance, in one case study, he suggests that the practitioner says, 'I'm not sure what you feel about it but evidence suggests that race/ethnicity/culture makes a big difference in what happens in mental health services. Usually for people of a BME background this isn't positive. I'm hoping together you and I can do something to turn the tide'. (p.42) Underpinning all these suggestions is the potentially empowering view that racism is 'institutional', rather than 'an evil act perpetuated by individuals'. (p.53)

Sewell concludes that 'Practitioners and service providers need to deconstruct the key knowledge, skills and attitudes in working with BME service users with mental health problems. These need to be rebuilt with the capacity and capability to work effectively with difference. Practitioners need to be honest about their fears, likes and prejudices and find ways to ameliorate their effects. They need to learn how to deal with matters that make them uncomfortable'. (p.183) The transformative potential of the relationship between workers and users is central to this handbook: 'These relationships are the carriers for change: the containers for all interventions provided by mental health practitioners.' (p.183)

This manual deserves to become a key text in addressing intercultural issues. It is a timely text, relevant not only for mental health settings, within clinical supervision and therapeutic training institutions, but also in educational and other contexts. Whilst the exercises and activities are cognitive and verbal in orientation, they could easily be adapted by dramatherapy supervisors and training institutions to a more action based approach. This text offers pragmatic ways to uncover the assumptions which can cloud professional judgement and impede the ability to relate to people as individuals. 'By advocating the practice of recognising the individuality of each service user, this book provides practitioners with the tools they need to work fairly and effectively.' (Fernando, p.11) It is truly 'a very practical book informed by common sense, a wealth of knowledge and clear thinking.' (Fernando, p.12)`

Nursing Standard (March 2009)

The service to our client group would improve beyond recognition if every mental health professional read this book. Hári Sewell, provides common sense approaches to culture and mental health. The questions at the end of each chapter provide opportunities to review practise in thought-provoking and non-threatening ways.

Sewell shows how to integrate best practice into any modern mental health service. A few hours with this book will provide more insight into the subject of race than many of the study days arranged by so-called experts.

The Psychologist (June 2009)

Every practitioner working in multicultural mental health services in the UK should find this book indispensable as it uncovers the importance of preconceived biases when working with service users from black and minority ethnic groups. Though the writing style is didactic and prescriptive, the recommendations are based on grounded research findings that emphasise changes that need to take place. Both from personal and managerial standpoints, the author forces the reader not to turn a blind eye to individual and institutional racism.

Sewell engages his audience in self-awareness by using examples based on mundane practise. The chapters are terse but accurate and therefore can be seen as a summative piece of the current state of knowledge in relation to the multi-ethnic service-user groups in mental health. But if the reader is looking for an international perspective or policy analysis this is not the book to start with.

The main strength of this read is that it is reflective of the current British patient cohort and as a result provides up-to-date practical knowledge to delivering and achieving to race equality.

British Journal of Social Work (March 2009)

The author has set out to meet the needs of basic-level front line practitioners who want to improve their working practices with people from black and minority ethnic groups (BME). With a particular focus upon the mental health field, the book meets a definite gap in the literature and will be of interest and value to many practitioners. With such an ambitious title, it is reassuring that, by and large, the content is rooted in what appears to be the author’s own extensive practice experiences. The foreword suggests that this is really a self-training book that will help improve those whose work is at the grass roots and who have little time for a more in-depth and perhaps academic text.

There are some especially useful parts to the book that should have a wider appeal than the intended audience. Of particular note is Chapter 1, with the emphasis of definitions and the understanding of the key terms ‘race’, ‘culture’ and ‘ethnicity’. This and the following chapter are where the author is at his most helpful, tackling head on issues of definition and applicability that are often ignored or that practitioners feel too inhibited to ask the difficult questions about.

Sewell has devised his own ‘seven elements for strengthening practice’, described in Chapter 6, and this will doubtlessly be helpful for those who need such a structure or guidelines when working with people from BME backgrounds who also have other ‘aspects’ to their identity. There is not too much theory to be found here but, instead, there are practical tips and helpful suggestions. This where the book is at its most useful, providing as it does a practice focus and readily accessible information for front line workers.

Alternatives to the ‘illness model’ are discussed, albeit briefly, in Chapter 9, as are the use of alternative approaches that are particularly relevant for a book with this focus on BME and the reality that psychiatry may not provide totally convincing explanations of phenomena that BME service users experience. Helpful examples of the Hearing Voices approach are used to illustrate the importance of alternative approaches. While the glossing over of key aspects and the compression of events like slavery and present-day cannabis use and mental health will cause some to want more, it may well be enough for a book like this.

As a ‘handbook’, the overall style allows for ‘dipping in and out’ pretty much at ease but, as a ‘self-training’ book, the use of exercises without answers leaves some doubts about the effectiveness on its own of this feature. For example, on p. 43, readers are invited to construct an action plan to overcome barriers to improving the effectiveness of work with BME service users or colleagues but no account is taken of the fact that the reader may not perceive that there is a problem or perhaps identify inappropriate actions.

Overall, an interesting book and although aimed at a specific market, it may also interest a broader range of people, especially students.