The Mental Health Act 1983 makes provisions for those suffering from mental illness and those under compulsory detention into mental institutions. Compulsory admission can only be made via an approved Social Worker or the nearest relative. The application will only be approved once the individual has been assessed by two medical practitioners. This process of ‘Sectioning’ a patient has led to many patients including David Bennett often being denied help and then end up being detained against their will once their situation has deteriorated.
The Equality of Human Rights Commission states that black people with mental health problems are eight times more likely (and in the North West 25 times more likely) than the overall population to be in high security psychiatric hospitals. Evidence suggests that service providers hold exaggerated fears linked to a ‘big, black and dangerous’ stereotype and that black people fear these services will harm them and so miss out on early intervention.
A study conducted by the Policy Study Institute indicated that Afro Caribbean people were only marginally more common to suffer from schizophrenia. This was based on a sample of people who had reported having relevant symptoms. In contrast to this a study which took place in 1987 found that British Afro Caribbean men who were between the ages of 16 and 29 were 7 times more likely to be diagnosed as schizophrenic then white males who were first admitted into hospital with mental health problems McGovern and Cope (1987).
Knowles (1991) however states that there is no authoritative concept of schizophrenia and that it is not a “clinical entity but a group of syndromes”. Knowles continues on to say that misdiagnosis can occur due to the limitations of psychiatry rather than a practitioner’s prejudices. This is an interesting point as symptoms do often overlap and interrelate and sharp distinctions do not exist which makes it difficult to diagnose Fernando (2002). However, important to note is that psychiatry is based on evaluations which involves a vast amount of information that the psychiatrist has gained from the patient and from others Fernando (2002). Depending on the psychiatrists beliefs, values and understanding this will impact on the way the psychiatrist interprets the information and treats the patients Fernando (2002). This suggests that such evaluations can be far from objective. Therefore the large amount of high diagnoses for schizophrenia amongst ethnic minorities could be due to racial prejudice, or lack of understanding from white psychiatrists towards ethnic minorities. It could also be because of the lack of trust and hostility between these racial groups Clair (1951), this in turn can lead to disadvantages in treatment towards black people. These issues are important because this means that people can be detained in hospital under the Mental Health Act 1983 sections 2 to 4 for a serious mental illness Peddler (1999).
It is important to note that psychiatry works on the basis of there being normalised behaviour but Knowles (1991) states that this involves conformity to Eurocentric expectation. This puts ethnic minority patients at a disadvantage as their ‘different’ behaviour could be due to their different upbringing and culture or just due to a reaction to the discrimination they have faced. Fernando (2002) stated that a typical syndrome amongst black people could easily be misdiagnosed as schizophrenia; this indicates that the psychiatric process can be discriminative therefore reinforcing institutionalising racism.
In David Bennett’s case it is highlighted that there was a large gap between the start of his illness and his first diagnosis which was cannabis induced psychosis. This illness stems from the idea that Black people should not smoke cannabis as it brings along this illness of cannabis psychosis which is mainly attached to black people Fernando (2002).
With regards to treatment for schizophrenia it can take the form of psychological and physical treatment. The decisive factors for selection include understanding of problems in psychological terms and motivation for insight etc Fernando (2002) and treatment is only suitable for selected people. The physical part of the treatment consists of electro convulsive therapy (ECT) and psychotropic medication and can be given without a patient’s consent. African Caribbean people are most likely to receive this type of treatment as opposed to psychotherapy and counselling Community Volunteer Service (1998). African Caribbean people are also more likely to be treated with larger than average doses of medication Bhui (1999), as was the case in David Bennett. Fernando’s (2002) answer to this is because psychiatrists accept the stereotypical view of black people. Another possible answer is that ethnic minorities are fearful of engaging with mental health services as they are afraid of what will happen to them. This in turn makes their situation worse and then they require the medication they were originally fearful of SCMH (2002).
This overrepresentation of African Caribbean’s arises from misunderstanding and discrimination when it comes to the use of compulsory power, which has resulted in the deaths of a number of African Caribbean service users while under the care of the mental health system, tragically highlighted by the death of David Bennett.
This is despite Governments statistics recommendations from the David Bennett inquiry that states:
The question of detention in and treatment of patients in secure accommodation should be reconsidered in order to ensure that no patient is detained in such accommodation unless it is necessary, and that the period of each detention and the treatment be kept constantly under review http://www.blink.org.uk/docs/David_Bennett_report.pdf.
The Government does not have seemed to have taken this into consideration as the introduction of The Mental Health Bill (introduced into the House of Lords on 16th November 2006) proposes important adjustments to the Mental Health Act 1983, specifically in relation to the detention of individuals with or without their consent.
Cluley (2008) having drawn on the Reed Review (The Review of Health and Social Care for Mentally Disordered Offenders) and the Bennett Inquiry, states that the report is critical of the lack of the Governments attempt to address the over-representation and maintenance of the institutionalised discrimination over the past 10 years. However the Delivering Race Equality in Mental Health Care document shifted the debate from deviancy and notions of dangerousness to socio-economic explanations which can be attributed more too institutionalised racism. The report highlights that not enough attention has been given to Black mentally disordered offenders by the DOH or Ministry of Justice. To improve this, the report has made three main recommendations. This is that there is more positive engagement with the black community, that there are provisions to monitor and utilize more efficient monitoring systems and to increase the awareness of practitioner’s awareness of how to deal fairly with the black community Cluley (2008).
With regards to David Bennett, he was restrained by 5 nurses who most probably perceived him as dangerous, which may have been due to stereotypical thinking. Browne (1995) highlights that there is a strong association in the minds of personnel between race and dangerousness which implies that black people are more likely to be seen as dangerous. However, David Bennett may have been seen as dangerous due to his history of violent behavior this may have led the staff to over restrain him. Regardless of this, the inquiry felt that three nurses would have been sufficient and that there was some evidence of negligence during the restraining period.
David Bennett was three times over the recommended dose of medication for Schizophrenia when he died, this occurred even though he had been seen by more than one doctor. This illustrates as outlined in the Macpherson Report (1999) that ‘institutional racism’ was not only found to be present within the Metropolitan police service, but also prejudice was found throughout public service and government. (Phillips and Bowling, 2003).
In tackling racism, The Department of Health and the public sector organisations which deliver mental health services have a duty to promote race equality and good race relations under the Race Relations (Amendment) Act 2000. Therefore it means that it is important that any proposals for changes to the workings of mental health services demonstrate that these duties will be better delivered by such changes.
Research appears to indicate that in terms of knowledge, expertise, and access to resources and statutory powers, mental health professionals seem to use their power in oppressive ways. Many institutions seem to be insensitive to the issues of powerlessness and oppression with regards to ethnic minorities. It can be said therefore that institutionalised racism is present in psychiatric services, Fernando (2002) highlights that racism is about value judgements and power.
Whilst in care David Bennett only received medication, he was not engaged in any other care package for his mental health. The Mental Health (Patients in the Community) Act (1995) states that medication; education and training should be in place for community care requirements. In the Bennett enquiry they found that there was no assessment of his ethnic needs, and the racial abuse that he suffered which led up to his death was not handled with sensitivity or care. David Bennett was instead led off to another ward after the racial abuse took place. The enquiry also stated that David Bennett’s family were not properly informed about his illness or treatment plans, the family were not engaged and there was nothing done to address his ethnic needs. Hawkins et al (1985) state that positive relationships, involvement and bonding within families have been identified as protective factors.
Evidence from the Mental Health Task Force is that black people and Ethnic minorities are dissatisfied with the care that they have received and generally find that mental health care is oppressive (Wilson, 1993; Wilson, 1995).
Institutionalised racism is emphasised as an explanation for these sorts of findings not least because of the historical record of prejudicial treatment of black and ethnic minorities by insensitive systems of care (Lago and Thompson, 1996; Fernando, 1998).Wilson,
1993; Wilson, (Wilson,
Dr Reed (1994) chaired a committee set up by the DOH and the Home Office examined the treatment of mentally disordered offenders from ethnic minorities. Certain points they highlighted were that equal opportunity policies should be available and monitored and more training with regards to dealing with ethnic minorities. It also highlighted that more work should be done with regards to multi agency work. Bhui (1999) argued that the Reed’s recommendations had not been adhered too, however many efforts have been put into place. One example being Haringey’s Council who have assisted a resource centre specialising in mental health, the group is run by people with mental health problems and 50% of the members are African Caribbean Community Volunteer Consultants (1998).
As a trainee Probation Officer, I had not previously had any offenders with Mental health problems on my case load. I have recently been transferred a case, this is a 26 year old black male who is more than half way through his order. He has mental health problems and has been engaging with a psychiatrist and having family counselling sessions with his mother. Having read his case file, the results appear to be very promising and he has been progressing well throughout his order. There was a close relationship between his previous Probation Officer, his family and the psychiatrist so that the best care package could be given to him. Also in my office we have a specialised Mental Health Worker who comes to our office every few weeks so that we can discuss any cases that we may have. This is very important and indicates that although it may not be enough some effort is being put in to address mental health problems that practitioners and institutions may have.
In my opinion it does appear that black ethnic minority groups do suffer from institutionalised racism within the mental health system. Within my practice I feel that I can help to address this by the way that I deal with mentally disordered offenders from ethnic minority groups. This will include understanding their different needs and cultures and not stereotyping different groups. It is also important to be aware of these factors when writing reports to the Court, as “Probation Officers occupy a pivotal position in the Criminal Justice System, have a major role in the assessment, diversion, management and perhaps the most controversially, treatment of such offenders, are consequently are in a position either to reinforce or redress the discrimination which exists in that system” Bhui (1999). However regardless of this I will always try to maintain a balance as it is important to realise that they can pose a risk of harm to themselves and others.
Fernando (1991) believes that if we are to gain a better understanding of mental illness, this will mean a general move towards greater understanding between people. Where, for an understanding of this unity, a realistic approach must be taken to the problems arising from differences in culture and the divisions arising from racism. The irony that mental health is different because of culture and race and yet the same irrespective of culture and race, is a reality that we have to face up to.
This discourse has studied the issues of ethnicity, culture and race. It has examined the case of David Bennett to look at whether there is institutionalised racism within mental health services and possible solutions to address these problems.
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