One of the terms of reference for the Independent Review of the Mental Health Act, which published its Final Report in December 2018, was to understand and make recommendations about “the disproportionate number of people from black and minority ethnicities detained under the act”. The authors of the Final Report described this issue as “one of the most troubling and difficult areas” they considered in conducting the review. Whole books could be written about this, but a short article will have to do.
Different communities have different experiences of mental health and of treatment. At the age of 11 there a very few differences, but by adulthood the picture is different. Black men and white men experience similar rates of common mental health problems but Black women experience substantially higher rates of them than white women. When it comes to psychosis Black men experience it around 10 times more frequently than white men. But despite Black people, in very, very broad brush terms, having worse experience of mental health than white people, the latter are more than twice as likely to be receiving treatment for mental health problems.
If one examines routes to treatment you will see that Black people are 40% more likely to access treatment through a police or criminal justice route, less likely to receive psychological therapies, more likely to be compulsorily admitted for treatment, more likely to be on a medium or high secure ward and be more likely to be subject to seclusion or restraint (56.2 per 100,000 population for Black Caribbean as against 16.2 per 100,000 population for white). We must stress that there is a hugely complex picture here, but it seems undeniable that Black people get to the sharper end of treatment in the more uncomfortable ways.
Dr Frank Keating examined this complex picture in his report “Breaking the Circles of Fear”. He found that Black people have a strongly grounded fear and mistrust of services (which they perceive as inhumane), resist seeking help and only present in the most aversive of care pathways at the point of crisis. Jacqui Dyer, the recently appointed Mental Health Equalities Champion, says that there is a belief in some Black communities that if you go into mental health services “it’s not that you get recovery, it’s that you die there”. Similarly some of the people from BAME communities that we engaged with in developing our submission to the MHA Review clearly told us that sectioning was not experienced as a therapeutic intervention, but as little more than chemical and physical containment.
If one looks at Mental Health Act (MHA) outcomes a pretty clear picture emerges along the same lines as statistics quoted earlier. Black people are 4 times as likely to be detained under the MHA and arrested under s. 136 twice as often and they are put on CTOS 8 times more frequently than white people.
The criteria for detention under sections 2 and 3 of the MHA and the criteria for arrest under section 136 involve, among other things, subjective assessments of whether someone poses a risk to themselves or others. These criteria in themselves might open the door to biases. Research on clinical decision-making suggests that clinicians hold negative implicit attitudes toward people from minority backgrounds and that there is a direct link between these attitudes and clinicians’ treatment decisions. Could it be that stereotypes of black people, men especially, as being dangerous are operating at a sub-conscious level on decision-makers at the point of sectioning?
On the criteria for detention, Mind urged the Review to work towards legislation that would give primacy to a person’s capacity to make their own decision rather than revolving around their mental disorder and the risk they are perceived to present. The Final Report of the Mental Health Act review did not take up our suggestion. It did, however, recommend tightening the criteria to say that there must be a substantial likelihood of significant harm and that risks would need to be evidenced. Its further recommendations included:-
- the development of a Patient and Carer Race Equality Framework (PCREF), developed and implemented by the NHS but rolled out to other public services
- more muscular regulator involvement (CQC and EHRC)
- culturally appropriate advocacy
- greater representation of people of African and Caribbean heritage at senior levels in mental health professions
- combatting bias in decision-making with piloted behavioural "nudges", and
- improved data and research on issues leading to mental disorder in BAME communities
The PCREF is a practical approach for organisations to monitor areas where there are disparities in outcomes, setting up processes to improve things while seeking the input of communities most deeply affected. But one problem with the PCREF is that no-one really seems to know exactly what it is or how it is going to work.
While we support the Review’s recommendations on race equality, we are very conscious that they will require a continuous commitment to tackling racial discrimination and increasing diversity and inclusion in wider mental health services to bring about significant and sustained change. We hope that the recommendations may be part of a solution to complex problems that have proved intractable for many decades but we will continue to campaign for race equality in mental health until there is genuine equality for all.