Introduction
Terminology Background Historical background
Population size
The African-Caribbean experience in Britain
African-Caribbean experiences with the mental health system
Access to the mental health system via the criminal justice system
The David 'Rocky' Bennett story
Breaking the Circles of Fear
Count Me in Census
The care of African-Caribbean women
Policy initiatives 1999–2009
Improving Access to Psychological Therapies (IAPT)
The Mental Health Act (MHA) 2007
Independent Mental Health Advocates (IMHAs)
Recommendations of the Bennett inquiry
Reporting of drug side-effects
Useful organisations
Further reading
References Copyright note for Mind factsheets: Both individuals and organisations are welcome to print and photocopy any factsheet. Organisations are free to distribute them to service users and colleagues, but must ensure they always use the latest version of the factsheet, as available on the website, at the time of distribution.
This factsheet gives an overview of how the mental health needs of the African-Caribbean community are negatively affected by many factors, including racism. It highlights examples of racism within society in general and the psychiatric system in particular. It also provides evidence indicating that African-Caribbean people face disproportionate discrimination and disadvantage, which has a significant impact on their life chances and a detrimental effect on their mental health. This factsheet explores the nature of mental health practice and places this into the wider historical and political context.
This factsheet has been written for students and mental health professionals. It may also be of interest to carers, users of mental health services and the wider public. More statistical information can be found in Mind's factsheet Race, culture and mental health (see 'Further reading').
One controversial aspect when writing about race and mental health issues is the terminology used. The terms 'Black' and 'African-Caribbean' are used to describe people of African descent, wherever they were born. For the Black people who have adopted it, this term affirms a rich heritage, positive identity, and a unity of experience that includes discrimination and exploitation.
The term ‘Black’ refers to any person whose skin colour renders them liable to the application of racism, irrespective of their ethnic background, linguistic or academic ability, country of origin and length of stay. [1] This reflects a broadening of ‘Black’ as a political construct, encompassing all ethnic groups who find themselves in a ‘minority’ status. In this case, ‘minority’ is partly about being of a numerically smaller group, though it also refers to having lesser access to/control of institutions and resources, through which power and authority are wielded.
In defining terms and groups, The Parekh Report asserts that the term 'African-Caribbean' should not imply that this is a homogenous group. African-Caribbean culture has numerous cross-cultural influences, including Africans, East Indians, British, Spanish, French, Dutch, Portuguese and Chinese. [2]
No single term is completely acceptable to everyone, but it is hoped that by using both ‘African’ and ‘Caribbean’, we include any individual with this heritage who experiences racism in whatever form. We hope we’ve done justice to the variety of identities and interpretations of the African-Caribbean diaspora.
When specific research studies are mentioned, we use the terminology of psychiatric diagnosis. This reflects the language of the sources referenced and in no way implies Mind's unqualified acceptance of such language.
The World Health Organization (WHO) defines health as "a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity". [3] In 1986, the Ottawa Charter for Health Promotion identified nine prerequisites for health:
This factsheet illustrates the extent to which the African-Caribbean community is disproportionately disadvantaged in most, if not all, of these prerequisites.
To place this in a wider context, it is important to take into account the finding of the Acheson report that persistent and entrenched inequality exists in the mental health provision for women, working class and old people. [4] Acheson indicates that mortality from poor mental health is higher in men than women, and that this is strongly influenced by socio-economic status. Working-class men are three times more likely to commit suicide compared with their more affluent and middle class counterparts, and old people are less likely to receive some healthcare services. [5]
Given that these entrenched inequalities already exist within the White community, it is not surprising that the African-Caribbean community faces disproportionate disadvantage and discrimination within the mental health system. Consequently, the provision of mental health services to people from African-Caribbean communities has been the subject of growing concern within both the African-Caribbean community and the mental health field.
The National Institute for Mental Health in England (NIMHE; now the National Mental Health Development Unit) provided an excellent explanation for why these inequalities persist given that the NHS has been in existence since 1948. [6] It pointed out that the British welfare state has ignored issues of discrimination. The assumption was that a range of standard services would be provided for those in need. However, evidence in the Acheson report [7] indicates that this is not the case. The report reveals glaring inequalities in the provision of healthcare, particularly to women, old people, the working class and Black and Minority Ethnic (BME) groups. The Department of Health (DH) has recently provided evidence of persistent inequalities in health, highlighting that the health of the most disadvantaged has not improved as quickly as that of the better off. These inequalities continue, and in some cases have widened. Such inequalities are often avoidable and always unjust. [8]
The WHO connects the impact of inequalities on mental health, explaining that the chronic stress of struggling with material disadvantages is intensified to a considerable degree by doing so in an unequal society. Chronic stress affects individuals through the neuroendocrine, cardiovascular and immune systems, which may be accompanied by health-damaging behaviours, violence, anger and despair related to occupational insecurity, poverty, debts, poor housing, exclusion and other indications of low status. The WHO reports that in the UK between 20 and 25 per cent of people who are obese or continue to smoke are concentrated among the 26 per cent of the population living in poverty and multiple deprivation. This is also the population with the highest rates of anxiety and depression. [9]
NIMHE considers that this occurs because different groups of people do not start from a level playing field: we live in a society that categorises people according to a range of social divisions – sex, skin colour, age, social class, sexual orientation and disability [10]. NIMHE quotes Geoff Paynes, who states that "it is impossible even to begin to think about people without immediately encountering 'social division”. This is indicative of the fact that we tend to perceive other humans according to the groups in which we believe they exist: male or female, Black or White, older or younger, richer or poorer. A host of psychological literature [11] [12] explains the value of such simplified processing in helping us to make sense of a complex world. However, it does cause us to place people into categories, adapting our behaviour and attitudes to them in terms of the slots we place them in.
Black people have lived in England in significant numbers since 1554, a reflection of the slave trade between Britain and West Africa at that time. [13] By the middle of the eighteenth century, there were 18,000 Black slaves in London alone, forming nearly three per cent of an estimated population of 650,000. The influence of slavery and colonisation has left an indelible mark on African-Caribbean people, not least familiarisation with many aspects of British life and institutions. [14]
Colonialism and slavery brought Europeans into contact with people living in Africa, Asia and the Americas. Both were underpinned by the ideology of ‘national superiority’ of White people; non-White people were seen as “less intelligent, under-developed, primitive and lacking emotion”. [15] The social values and ideologies at that time permeated into psychiatry and influenced its development in various ways. Suman Fernando argues that the disciplines of psychiatry, psychology and sociology emerged during times when colonisation and slavery were at a peak. The views that Black people are born with inferior brains and have limited capacity for growth, and that their personalities tend to be abnormal because of genetic and environmental factors, were considered normal at the time. It is hardly surprising that these forms of racism have seeped, or were actively absorbed, into the theory and practice of psychiatry. Indeed, observations by psychiatrists in the USA during the time of slavery strongly suggest that psychiatry helped to reinforce racism and justify slavery. [16] Slaves who ran away from captivity were diagnosed as having ‘Drapetomania’ (an urge or mania to flee, then diagnosed as a mental illness). The treatment was captivity and return to bondage.
In the UK, large groups of post-war economic immigrants came from the poorer Commonwealth territories, which included the Caribbean, under the British Nationality Act 1948. Under this Act, citizens of the British Commonwealth were allowed to enter Britain freely in order to find work and settle. Many took this option as a result of recruitment schemes run by employers and the Government; for example, London Transport and the National Health Service. Many were soon joined by their families.
Even when immigration was encouraged for economic reasons, attitudes towards the newly arrived African-Caribbean people were inconsistent. [17] Particularly memorable for African-Caribbeans today was the arrival in Britain of the ship SS Empire Windrush in 1948, which had 500 ‘West Indian’ passengers on board who had come to start a new life in Britain; however, a large number of them returned home immediately after encountering a hostile environment that was ill-prepared for minority groups.
The McCarren-Walter Act, an American Immigration Act passed in 1952, restricted the immigration of people from the West Indies to the USA and resulted in a further 50,000 West Indians settling in Britain by 1956.
The UK population was estimated at just fewer than 59 million in the 2001 Census. It was estimated to have grown to 60,975,000 in mid-2007. [18] The average age of the population increased from 37 years in 1997 to 39 years in 2007. Children under 16 years represent about one in five of the total population, around the same proportion as those of retirement age. The Office for National Statistics attributes the increase from 59 million to 60,975,000 to an increase in the arrival of Central and Eastern European migrants of almost 15 per cent.
Data for a comprehensive breakdown of the UK‘s minority ethnic population are taken from the 2001 Census. However, this census is now out of date, and it is reasonable to conclude that the BME population has increased by a few percentage points since then.
The size of the minority ethnic population was 4.6 million in 2001 – 7.9 per cent of the total population. Indians were the largest minority group, followed by Pakistanis, those of mixed ethnic backgrounds, Black Caribbeans, Black Africans and Bangladeshis. The remaining minority ethnic groups accounted for fewer than 0.5 per cent each, but together for a further 1.4 per cent of the UK population. The African-Caribbean population was estimated to be 1 per cent of the 59 million. [19] The UK population by ethnic group in April 2001 is shown in the table below.
UK population: by ethnic group, April 2001
|
Ethnic group |
Count |
Proportion of UK population (per cent) |
Proportion of minority ethnic population (per cent) |
|
White |
54,153,898 |
92.1 |
n/a |
|
Mixed |
677,117 |
1.2 |
14.6 |
|
Asian or Asian British |
|||
|
Indian |
1.053,411 |
1.8 |
22.7 |
|
Pakistani |
747,285 |
1.3 |
16.1 |
|
Bangladeshi |
283,063 |
0.5 |
6.1 |
|
Other Asian |
247,664 |
0.4 |
5.3 |
|
Black or Black British |
|||
|
Black Caribbean |
565,976 |
1.0 |
12.2 |
|
Black African |
485,277 |
0.8 |
10.5 |
|
Other Black |
97,585 |
0.2 |
2.1 |
|
Chinese |
247,403 |
0.4 |
5.3 |
|
Other ethnic groups |
230,615 |
0.4 |
5.0 |
|
All minority ethnic population |
4,635,296 |
7.9 |
100 |
|
All population |
58,789,194 |
100 |
n/a |
As the WHO indicates, socio-economic and political factors have direct implications for health and mental health. [20] This section summarises the experiences of African-Caribbean people in the UK.
Many studies from the 1970s, 1980s and 1990s highlighted that African-Caribbean people experienced racist insults and abuse. It is estimated that up to 20,000 African-Caribbean people suffer a physical assault each year. [21], [22]
African-Caribbean people are treated differently in all stages of the criminal justice system, and are disproportionately affected by the 'stop and search' policy. [23] Black African suspects are more likely than White suspects to be arrested and tried by courts, and are six times more likely to be in prison and be given longer sentences. [24]
In education, serious inequalities have been identified since the then Department of Education and Science published the Rampton Report in 1985. [25] African-Caribbean children start school at the age of five at much the same standard as the national average. By the age of 10, however, most have fallen behind. The Government’s own figures consistently indicate that the proportion of African-Caribbean students achieving fewer higher grades is "considerably less than the national average". The Rampton report stated that the curriculum failed Black boys in particular, and that teachers had low expectations of Black children. Black boys were, and still are, over-represented in school expulsions.
Media coverage of the African-Caribbean people is still frequently negative, patronising or completely ignored. [26]
In employment, many of the descendants of the original labour migrants continue to be employed in low-paid and insecure jobs, and have lower wages than the national average. Many individuals who are in work have good or excellent qualifications, but nevertheless have greater difficulty than their White counterparts with the same qualifications in gaining the most sought-after jobs.
The persistence of all these forms of discrimination (and others not discussed in this factsheet) were emphasised in the Macpherson Report, published in 1999. [27] The report, commissioned by the Home Secretary, conducted a detailed review of the circumstances surrounding the murder of Stephen Lawrence. The report confirmed what was already well known and experienced by most African-Caribbean people – the existence of institutional racism. The report considers the various forms and manifestations of racism.
Macpherson defines racism as "consisting of conduct or words or practices which disadvantages or advantages people because of their colour, culture or ethnic origin." Parekh elaborates on this definition and argues that racism involves stereotypes about difference, inferiority and the use of power to exclude, discriminate or subjugate. [28] Macpherson [29] makes much reference to Lord Scarman's views of racism. [30] Macpherson defines institutional racism as "the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudices, ignorance, thoughtlessness and racist stereotyping, which disadvantages Minority Ethnic groups.” Although this definition has its critics, it encapsulates much of the African-Caribbean experience in Britain.
Notwithstanding the existence of institutional racism in the wider society, race relations in the UK have been compromised since the implementation of a series of anti-terrorism laws following the bombings in London on 7 July 2005. The Terrorism Act 2000 and Anti-terrorism, Crime and Security Act 2001 include tagging people, keeping them under house arrest and banning suspects from using mobile phones and the internet.
The enforcement of the above legislation, according to a report by Liberty (The National Council for Civil Liberties), [31] has resulted in significant number of BME people being criminalised. The report points out that although these Acts were used disproportionately against the Muslim community, they do not leave the African-Caribbean Community untouched, as many could well be both African-Caribbean and Muslim. BBC News [32] supports the above argument. A Metropolitan police survey in 2004 [33] found that the number of Asians (who “look like Muslims”) who were stopped and searched by police rose by 41 per cent between 2000–01 and 2001–02, and searches of Black people (including African-Caribbeans) rose by 30 per cent, compared with an eight per cent rise for White people over the same period. Lawyers and groups representing Muslims have also noted an increase in complaints from individuals who report being subjected to police ‘stop and search’ powers, and having their cars and homes searched. [34]
As well as having an adverse impact on BME people (including African-Caribbeans), the anti-terrorism laws appear to be a significant factor in influencing race relations in Britain. A BBC poll conducted in 2008 [35] warned that “almost two-thirds of people in Britain fear that race relations are so poor that tensions are likely to spill over into violence”. It also pointed out that three out of four people thought there was now ‘a great deal’ or ‘a fair amount’ of tension between races and nationalities.
In the final analysis, the combination of anti-terrorism laws and their impact placed immigration and race relations firmly back on the political agenda. These recent developments have, arguably, exacerbated the contemporary situation, which does not bode well for the WHO’s prerequisite for health – namely peace, social justice and equality of opportunity for all.
Under Section 95 of the Criminal Justice Act 1994, the Home Secretary has a duty to publish annually any information that will enable criminal justice agencies in England and Wales to help prevent racial discrimination. Ethnic monitoring of key police activities, such as arrests and ‘stop and search’, became mandatory for all police forces from April 1996. [36] Unfortunately the rates of these appear to be increasing with the impact of the latest anti-terrorism laws.
Several studies in the 1980s showed that Black people were more likely to be detained under Section 136 of the Mental Health Act 1983. [37] (Section 136 allows a police officer to arrest an individual he or she believes to be suffering from a mental disorder in a public place and take them to a ‘place of safety’.) By the late 1990s, research into this issue, looking at both race and gender, discovered that similar worrying patterns had continued. The Mental Health Task Force Project (a research project supported by the then NHS Executive – a branch of the DH) reported that African-Caribbean males were over-represented among those formally detained in acute inpatient units, and were more likely to be 'taken to a place of safety' under Section 136. They were also up to three times more likely to be sectioned than their White counterparts. [38]
Black women also fare extremely badly, with a staggering 18 per cent likely to be held under this particular Section, compared with just two per cent of their White counterparts.
The police are involved in many mental health referrals, not just those involving Section 136 of the Mental Health Act 1983. Research has shown that the police are inconsistent in their use of this Section, and detain a higher proportion of African-Caribbean people.[39] When asked about African-Caribbean people's entrance into hospitals on a Section, consultants responded that it was usually through contact with the police, a general practitioner (GP) or an accident and emergency department. This indicates that they would be placed on either a Section 136 or a Section 4 (as an emergency admission).
Black Mental Health UK [40] also reported that Black African-Caribbeans, particularly men, coming into contact with the police were more likely to have samples of DNA taken and stored on the national criminal database. Black Mental Heath UK has highlighted serious concerns over the impact of database on criminalising vulnerable mental health patients who are detained in police custody. Thankfully, Home Office plans to keep innocent people’s DNA on the national database for up to 12 years have now been dropped.
In contrast, a study by Eleanor Cole and colleagues found that ethnic status did not determine whether police were involved as point of contact for people with a first episode of psychosis. [41] The significant factors associated with compulsory detention in this study were living alone, the absence of GP involvement and the lack of a relative or friend in negotiating access to appropriate care.
The David 'Rocky' Bennett case encapsulates many of the issues faced by African-Caribbean people within the mental health system. David Bennett was an African-Caribbean man with a diagnosis of schizophrenia who had been receiving treatment for his mental health problems for approximately 18 years before his death. He was an inpatient at the Norvic Clinic in Cambridgeshire. As a young man, he was a talented footballer and musician. David became mentally unwell in the 1980s and was seen by a psychiatrist.
David was hospitalised on two occasions between 1980 and 1984. He had been under probation or imprisoned on several occasions, and had a history of unprovoked assaults on both staff and patients. [42]
At the outset of David’s contact with mental health services, the psychiatrist was dismissive of David and believed that his problems were due to 'cannabis intoxication'. Some years later, however, David was diagnosed with schizophrenia. No explanation was offered to the family to inform them of what schizophrenia was, and David’s family were left to care for him.
David frequently reported being harassed and bullied by other patients. However, the inquiry after his death revealed that there was no record of any action taken by staff. Black staff also experienced racism from White clients. The care David received in the community consisted only of injections of medication. The authorities showed no interest in his life, ambition, education, employment or how the family was coping.
Whilst at the Norvic Clinic, David was over-medicated to the extent that his blood pressure was well below the normal level for his age. This got worse when David raised various issues. He was seen as a nuisance, and his medication continued to be increased. His cultural, racial and social needs were not attended to. No attempt was made to engage his family in his care and treatment, and no information was provided about his illness.
On the evening that he died, David had been involved in an incident with a White patient in which the two men struck out at each other. David had also been the recipient of repeated racist abuse from the other patient. After the incident, David was given some medication and moved to another ward. David questioned why he was the one being sent on to another ward. In an attempt to diffuse the situation, the staff nurse who was escorting him said, "Well you need to."
After some time, another nurse informed David that the decision had been taken that he should stay on the other ward. David hit the nurse and was physically restrained by a number of nurses. He was brought to the floor and placed in a face-down position. During the prolonged struggle he collapsed and died. David's sister Joanna Bennett launched a public campaign for a public inquiry.
The independent inquiry on David Bennett's death was set up by the Norfolk, Suffolk and Cambridgeshire Health Authority after consultation with the DH. The inquiry took detailed evidence from the clinic staff and from other specialists in the field of mental health. It made reference to the reports of the committee of inquiry into the deaths in Broadmoor Hospital of Orville Blackwood in 1993 and two other African-Caribbean patients, Michael Martin and Joseph Watts. Most of the recommendations arising out of the Orville Blackwood inquiry had not been acted upon.
The Bennett Inquiry made 22 recommendations (see ‘Recommendations of the Bennett Inquiry’). The key theme underpinning most of these was that there should be ministerial acknowledgement of institutional racism existing in the mental health services, and a commitment to eliminate it. [43]
The experiences of David 'Rocky' Bennett are encapsulated by findings of a two-year research study conducted by the Sainsbury Centre for Mental Health. This study focused exclusively on the mental health services received by African-Caribbean people, and is aptly named Breaking the Circles of Fear. Over and above the concerns that arose out of the Bennett story, Breaking the Circles of Fear identified other concerns. [44]
Inside Outside [45] supports most of the findings of the David Bennett inquiry and Breaking the Circles of Fear. It states that current mental health services over-emphasise institutional and coercive models of care, and professional and organisational requirements are given priority over individuals’ needs and rights.
The above publications supported the finding of the Bennett inquiry of institutional racism within mental health care. They highlight overall that there does not appear to be a single area of mental health care in the UK in which Black people, including African-Caribbean people, fare as well as the majority White community.
Mental health outcomes for Black patients are shown to be poorer in terms of re-admission. GPs appear to have a limited capacity to recognise psychiatric disorders in Black patients compared with other patients. This supports other evidence that confirms that Black patients are more likely than White people to go into specialist mental health care by coercion (that is, through either the police or the criminal justice system).
Black groups are more likely to be misunderstood and misdiagnosed and are more likely to receive electroconvulsive therapy than talking treatments. Black clients are more likely to stay in hospital longer, and are less likely to have their psychological needs addressed. The rights and healthcare needs of this group are less likely to be taken seriously than those of White clients. Black clients are also more likely to be under supervision, subject to physical treatment, and are over-represented in high and medium security settings. Their relatives feel unable to participate in treatment plans. [46], [47], [48], [49], [50], [51], [52] The Healthcare Commission raised similar issues via the annual Count Me in Census in 2005. [53]
The Count Me In Census was a joint initiative between the Care Services Improvement Partnership (CSIP)/NIMHE (now NMHDU) and the Healthcare Commission and Mental Health Act Commission (MHAC, which merged in April 2009 to become the Care Quality Commission [CQC]). The Healthcare Commission, CSIP and the MHAC were responsible for coordinating the Census in 2005, 2006, 2007, 2008 and 2009. [54] The Census forms part of the Delivering Race Equality (DRE) programme, started in 2005. It requires the Mental Health and Learning Disability Services in England and Wales to:
The results of the latest Count me in Census were published in November 2008 and make the following conclusions.
Although the Count Me In Census provides a detailed and unique picture of inpatient activity for given years, its methodology has been criticised. It has been argued [56] that mental health inequities between different groups of patients are best measured by comparing minority groups against the majority group, rather than the overall average used in the Count Me In reports.
The same authors criticise the Healthcare Commission for approaching the data with “a spurious insistence of statistical significance” which masks the fact that all Black groups show higher bed occupancy ratios than the White British population, and that most BME groups have substantially higher rates of bed occupancy than White British inpatients. Both the biennial reports by the now defunct Mental Health Act Commission [57], [58] collected data on deaths of detained patients from 2000–04 and 2005–08. The data appears to show a higher proportion of BME patients in the ‘unnatural death’ category. However, this point is not elaborated upon.
African-Caribbean women face several forms of discrimination, including sexism and racism. NIMHE [59] and The Parekh Report [60] argue that these forms of discrimination reinforce each other in a vicious circle to such an extent that it is impossible to disentangle them.
White feminists may have provided valuable and challenging research literature on gender in, among other areas, caring for the sick, the masculinisation of medicine, the journey of being a mother and the sexist nature of medical sociology, but these have routinely excluded the Black women's perspective. [61]
African-Caribbean women bring distinctive insights and experience to both feminism and anti-racism. However, they frequently find that they have to struggle against sexism and racism not only within society generally but also against racism within White feminist movements and sexism within anti-racist movements. Moreover, race equality initiatives tend to benefit mainly Black men, and gender equality initiatives mainly White women. [62] More specifically, Women's Mental Health into the Mainstream, the latest policy initiative on women's mental health from the DH, makes only occasional reference to the views and experiences of African-Caribbean women in mental health services. [63] More evidence of this can be seen in the recent publication Women Detained in Hospital by the Mental Health Act Commission, which, in its 37 pages, makes no reference to racism or sexism, and highlights ‘cultural awareness’ in less than half a page. [64]
The mental health experiences of African-Caribbean women are beginning to appear in more recent research. Corliss Heath [65] argues that issues of gender, race and class contribute to Black women’s mental health status. This may well be a significant factor in explaining why Black women constitute 25 per cent of the prison population (compared with two per cent of the female baseline population). [66]
In psychiatric hospitals, Black women in secure settings are 20 per cent more likely to be diagnosed with psychosis. They are also more likely to have their children removed. By comparison, White women on the whole tend to be diagnosed with personality disorder. Further, Black women rarely present with symptoms of perinatal depression, [67] and their mental health problems are less likely to be identified by GPs. [68] Suicide may well be a matter of serious concern, but the lack of ethnicity monitoring does not allow for any reliable conclusion to be drawn.
Most of the creative means to meet the needs of African-Caribbean women come from community-based initiatives, mostly from Black women themselves. [69]
Since the Labour Government was elected in 1997, the DH has consistently raised the profile of mental health services, and published the National Service Framework (NSF) in 1999. [70] Arguably, this was a momentous occasion for all those who worked and engaged with mental health services. The NSF had distinct standards, centred on mental health promotion, primary care, access to services, services for severe and enduring mental illness, and caring for carers.
Nevertheless, this major initiative had its shortcomings. The Sainsbury Centre for Mental Health argued that the NSF was not fully resourced and paid too little attention to entrenched and deep-seated inequalities generally, but more specifically the serious inequalities faced by people from BME groups.[71] The policy patently failed to take heed of a large amount of evidence available since 1971 which revealed glaring, persistent and unacceptable discrimination faced by African-Caribbean people.
In 2005, the DH published Delivering Race Equality in Mental Health Care (DRE), a five-year action plan ending in March 2010. [72] This document draws on previously discussed publications, such as Inside Outside. [73] The key principles of DRE were threefold: more appropriate and responsive services; community engagement and better information.
The DRE document states that it would support the implementation of Sir Nigel Crisp's 16-point race equality plan [74] in the NHS, and accepts most of the recommendations from the Bennett Inquiry, though it rejects the existence of institutional racism in the mental health services.
The DRE plan relegates the existence of institutional racism to direct and indirect discrimination. In doing so, it ignores the findings of the Macpherson report [75] and most, if not all, the evidence available to the mental health services since the 1970s. Furthermore, it fails to place into context the various forms of direct and institutional racism in wider society. The DRE talks about training, employment issues and the ways in which BME people should be treated within mental health services. However, it works on the assumption that the knowledge base of psychiatry is value-free and culture free, and does not acknowledge Fernando's view that most of the values and belief systems inherent in psychiatry are steeped in eurocentricity. [76]
Another flaw in the DRE programme is that it relies heavily on the Race Relation (Amendment) Act 2000. While this may improve some of the issues faced by African-Caribbean people, there is little evidence to suggest that the Race Relations Act 1976 had any impact on the clinical experience of this group within mental health services. A report from the University of Central Lancashire argues that the Race Relations (Amendment) Act 2000 has no bearing on clinical decisions. [77]
The National Service Framework (NSF) for Mental Health came to an end in 2009, and the DRE programme completes its lifespan in March 2010. In anticipation of the demise of these two initiatives, the DH [78] launched New Horizons: Towards a shared vision for Mental Health. This document was subject to a consultation phase, completed on 15 October 2009. New Horizons will build on the achievements of the NSF and consists of some key themes: prevention and public health, challenging stigma, early intervention, personalised care, multi-agency commissioning/ collaboration, innovation, value for money and strengthening transition.
In essence, the document places significant emphasis on the promotion of mental health and the transformation of specialist services. It builds on the principles and values set out in the NHS Constitution, and stresses the importance of joint working between commissioners and service providers, and use of the growing understanding of the wider determinants and social consequences of mental health problems. It identifies the root causes of poor mental health, the key risk factors, and the at-risk groups whose needs require addressing, and the need to address inequalities in health.
The New Horizon consultation document has been welcomed by the Sainsbury Centre for Mental Health. [79] Black Mental Health UK [80] agrees that New Horizons offers the opportunity to ensure that the failures highlighted within mental health services in the Bennett Inquiry report are taken forward and addressed through this new strategy. It goes on to suggest that there must be moves away from the medical model and admitting a disproportionate number of Black patients into secure psychiatric settings.
New Horizons covers the mental health needs of adolescents, adults and older adults. It makes some reference to the DRE programme and equality legislation. However, neither the Bennett Inquiry report nor the Macpherson report are included in the 179 references and sources. There is no mention of institutional racism in wider society or, by implication, in the mental health system.
The Afiya Trust [81] notes that the Equality Impact Assessment for New Horizons was based on a selective and limited literature review. There was no engagement with stakeholders to develop a robust impact assessment, and little significant and sustained consultation with the African-Caribbean community. The Afiya Trust also commented that the document takes a ’colour blind‘ approach, which will again marginalise the mental health needs of the African-Caribbean community.
As indicated by Inside outside, Breaking the Circle of Fear and the Bennett Inquiry Report, African-Caribbean clients do not have their psychological needs addressed. The DH’s IAPT programme [82] is a major development in mental health services and an important advance in treating common mental health problems. This new psychological service is being rolled out throughout England and is supported by an investment rising over three years to £173 million by 2010–11.
Based on guidelines published by the National Institute for Health and Clinical Excellence (NICE), the services offer evidence-based treatment for depression and anxiety disorders. To date, the investment has focused on training a new workforce in cognitive behaviour therapy. This approach is expected to help up to 50 per cent of those who complete treatment. Most of the focus has been on adults of working age, but some trusts have explored the particular needs of children and adolescents, new mothers, people from BME groups, older people, people with long-term conditions or disabilities and offenders. The Mental Health Act biennial report [83] views this as a positive move, but sees operational difficulties in the form of waiting lists, such that clients are unlikely to benefit while they are inpatients.
With reference to African-Caribbean clients, the report argues that if the IAPT programme is too community focused, hospital detention may be a bar to access. Fernando [84] elaborates by stating that the issue is not just about access to psychological therapies, but more importantly the nature of what is offered in the way of psychological interventions. He argues that interventions for African-Caribbean people must be geared to their needs, use models that are consistent with their cultural backgrounds, and carried out by people who are able to form constructive therapeutic relationships with clients from these communities. The client experience of racism in the wider society and the mental health system is a critical matter that should be discussed. Fernando argues that the Black voluntary sector is most suited to this kind of work.
The groundwork for the Mental Health Bill 2006 (which was introduced to amend the Mental Health Act 1983) began in 1998 with the appointment of the Richardson Committee. After several years of consultation and redrafting of the legislation, the Amendments to the 1983 MHA received Royal assent in 2007. Most of the amendments came into force on 3 November 2008.
The main amendments are:
The Amendments to the MHA 1983 were severely criticised during the consultation phase. The national organisation, BME Network, was so concerned about some of the Amendments that it made alternative suggestions to the DH. [85] The central argument was that anti-discriminatory and culturally appropriate services ought to be enshrined in primary legislation. Inyama [86] pointed out that the DH had a legal obligation to conduct a race equality impact assessment on the proposed Act, and that this should be done using the guidelines set out by the Commission for Racial Equality (CRE). A race equality impact assessment was conducted, but was itself criticised by the CRE’ s own members for not honestly representing the advice they were given. In the final analysis, the DH did not deviate from its stance in supporting the main thrust of the Mental Health Act.
Major concerns about the impact of the MHA Amendments 2007 on African-Caribbean people were about SCTs and the provision of advocacy. The issues with SCTs were twofold. First, the DH’s own research on the effectiveness of SCTs was inconclusive; second, Mind [87] argued that SCTs would discourage patients from seeking help when they needed it. It was predicted that SCTs would be used to manage the shortage of beds. [88] More problematic is the huge rise in the numbers of clients on SCTs, to 2085 by the end of May 2009, while the DH predicted only 450 over the whole year.
SCTs will certainly have a disproportionate impact on African-Caribbean men in particular, given the over-representation of African-Caribbeans within the mental health system. It will also be possible for clients from this group to be discharged to unsuitable, poorly staffed accommodation where nobody will know what they are doing most of the time. [89]
The MHA 1983 Code of Practice (revised 2008) [90] illustrates how IMHAs would provide an additional safeguard for patients who are detained under some Sections of the new Act. IMHAs are specialist advocates trained to work within the framework of the Act to meet the needs of patients. This service does not replace any existing advocacy and support services. However, only some patients would qualify for this service (i.e. those who are detained under the Act (even if they are on leave), conditionally discharged restricted patients, those subject to guardianship and those on SCTs). The role of the IMHA is to support patients to understand and exercise their rights under the Act to care and treatment.
Notably, the IMHA service was implemented in April 2009, while the other amendments were implemented on 3rd November 2008. This meant that those who were detained in November 2008 were not eligible for an IMHA at the time.
So how does the IMHA service impact on the mental health of African-Caribbean people? In an extensive review, the Social Care Institute for Excellence [91] argued that there is strong evidence that mental health advocacy services in general do not engage with African-Caribbean men in particular, due in part to the widespread lack of a strategic approach to the development of advocacy services. There is a broad consensus that advocacy services have to be culturally sensitive, but this is currently underdeveloped. Most participants in the study expressed the desire to have “an advocate like me”, who is able and willing to encapsulate the experiences of racism and discrimination that African-Caribbean people experience in the wider society as well as in mental health services.
There was also a strong consensus that IMHA services could be provided by the Black voluntary sector; it is high time that the skills and expertise of these agencies are formally recognised. The role of the Black voluntary sector would not only be to assist and empower clients, but also to be instrumental in tackling social disadvantage and its root causes.
The recommendations of the Bennett Inquiry provide the basis of a good model to address the needs of BME inpatients and probably all sections of the community.
The impact of both the Human Rights Act 2000 and the Race Relations (Amendment) Act 2000 has yet to be experienced by the public and, more to the point, by the African-Caribbean community. Against this backdrop, there needs to be more emphasis to implement the recommendations of the Bennett inquiry, including the development of a BME mental health strategy. The inquiry made a number of recommendations in its report [92], the main ones being as follows.
Mind's yellow card scheme for reporting the side-effects of psychiatric drugs, which started in 1994, was based on the official Yellow Card scheme (see ‘Useful organisations’) used by doctors, dentists, pharmacists and nurses for reporting suspected adverse drug reactions to the Medicines and Healthcare products Regulatory Agency (MHRA), the UK regulator. (For further information see Mind’s factsheet, The history of Mind).
Mind introduced its own scheme for mental health service users taking psychiatric drugs, rather than for health professionals, inviting people to report side-effects and other aspects of their treatment. The scheme showed how unpleasant and disabling, and in some cases even life-threatening, the side-effects of psychiatric drugs could be. It highlighted the need for better information provision, more say for people in their treatment, and support for managing withdrawal.
The scheme was relaunched in 2000, with the specific aim of seeking information on prescribing practice for people from BME communities, and a report was published in 2001. [93] Finally, in 2005, the MHRA launched a trial scheme for users of medicines to report adverse effects directly, and this scheme was made permanent in 2007. [94]
Afiya Trust
27–29 Vauxhall Grove, Vauxhall, Lambeth SW8 1SY
tel: 020 7582 0400
www.afiyatrust.org.uk
The Afiya Trust, led by BME groups, aims to reduce inequality in health and social care provision for racialised groups.
Black Mental Health UK
tel: 07852 182 750
email: editor@blackmentalhealth.org.uk
web: www.blackmentalhealth.org.uk
Black Mental Health UK (BMH UK) was established in 2006 to raise awareness and address the stigma associated with mental illness. It aims to reduce inequalities in the treatment and care of people from African-Caribbean communities who use mental health services, and to inform these communities on how to influence the strategic development, policy design and implementation of services. Its focus is to empower African-Caribbean communities to improve the experiences of Black service users and to reduce the over-representation of Black people at the coercive end of psychiatric care.
Care Quality Commission (CQC)
Citygate, Gallowgate, Newcastle Upon Tyne NE1 4PA
tel: 03000 616 161
email: enquiries@cqc.org.uk
web: www.cqc.org.uk
The CQC is the independent regulator of health and social care in England. It also protects people detained under the Mental Health Act.
Equality and Human Rights Commission (EHRC)
London office
3 More London, Riverside, Tooley Street, London SE1 2RG
helplines: 0845 604 6610 (England); 0845 604 5510 (Scotland); 0845 604 8810 (Wales)
email: info@equalityhumanrights.com
web: www.equalityhumanrights.com
The aim of the EHRC is to promote equality and human rights, and to create a fairer Britain, by providing advice and guidance, working to implement an effective legislative framework and raising awareness of individuals’ rights. Contact details for regional offices can be found on the website.
National Mental Health Development Unit (NMHDU)
Wellington House, Area 305, 133–155 Waterloo Road, London SE1 8UG
web: www.nmhdu.org.uk
The NMHDU was launched in April 2009, replacing the NIMHE. It provides national support for implementing mental health policy by advising on national and international best practice to improve mental health and mental health services.
Yellow Card scheme
tel: 0808 100 3352
web: www.yellowcard.gov.uk
The Yellow card scheme, run by the Medicines and Healthcare products Regulatory Agency, enables anyone to report the side-effects of a medicine.
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This factsheet was written by Navin Foolchand in November 2006, and updated by the author in November 2009.