As society becomes more and more open to conversations about mental health and wellbeing it’s essential that we address the issue of Black mental health and the systemic inequalities Black people face when encountering mental health services. The Equality and Human Rights Commissions publication, Healing a divided Britain: the need for a comprehensive race equality strategy, reports that in the year 2014/15 3.6% of the White adult population in England had accessed NHS-funded specialist mental health services for adults compared with 4.8% of Black/African/Caribbean/Black British population (Health and Social Care Information Centre, 2015).
The Mental Health Foundation identifies a range of negative influences of BAME communities’ mental health which may account for the higher rates of mental ill-health amongst Black people. These are: racism and discrimination; social and economic inequalities; mental health stigma; the criminal justice system; and other factors. Put simply racism, including systematic and institutional racism, is damaging to mental health.
Whilst the data demonstrate a higher prevalence of mental ill-health amongst the Black population of Britain, this cannot explain the much higher rates of compulsory detention of Black people under the Mental Health Act 1983. Indeed, in England and Wales, of Black or Black British people who stayed in hospital in 2014/15, 56.9% where compulsorily detained. Among White people, the percentage was 37.5% (HSCIC, 2015). The statistics become even more stark when you consider the intersectionality of ethnicity and gender. In 2014, the probability of Black Africa women being detained in England and Wales was more than seven times higher than for White British women. Black Caribbean and Black British women are four times more likely to be detained compared with White British women, and Mixed Black/White women were almost seven times more likely to be detained that White British women (Commission on Acute Adult Psychiatric Care, 2016).
So, what’s going on? In a blog post for the Runnymede Trust Suman Fernando, author of Mental Health Race and Culture Third Edition, argues that mental health services “have not adapted adequately to the fact that the understanding of what is ‘mental health’ and ‘mental illness’ is culturally determined”, that “the lack of scientific objectivity [in psychiatric diagnoses] means that in many instances stereotypes and assumptions based on perceptions of cultural and racial ‘types’ result in the practice of psychiatry often being biased, coming over in practice as being institutionally racist and culturally insensitive” and that in particular the “stereotype of ‘big black and dangerous’ play[s] a powerful role” in the UK. Black people are “significantly over-diagnosed with stigmatising ‘conditions’ such as ‘schizophrenia’; are under-referred for talking therapies but instead given large doses of drugs which cause long-term physical problems; and are over-represented among sectioned patients, people served with community treatment orders and those incarcerated in secure hospitals (as ‘dangerous’)”.
What can be done? Race on the Agenda (ROTA) and the Race Equality Foundation (REF) made numerous recommendations to the Mental Health Act Review in 2018. These were:
1. The Mental Health Act (the Act) should set out principles that define human rights, anti-discriminatory practice and a commitment to combat institutional racism.
2. The Act should be amended to include a clause that states explicitly that a diagnosis for a ‘mental disorder’ must take account of the patient’s social and cultural background. And the Act should allow for appeals against diagnoses via a Tribunal, with a panel that includes experts from BAME backgrounds.
3. Patients detained under the Act should be empowered to choose which carers or family members have a say in their care and can support them during an appeals process.
4. A new system of appeal whenever a new diagnosis is applied and/or continued, to a tribunal-like body, with the right of the patient concerned to have legal representation at the hearing.
5. All mental health service providers should be set targets to reduce the use of CTOs and minimise racial inequalities in their use. This should be monitored by the CQC during inspections. Specific amendments in relation to supervised treatment in the community should be made to ensure this is statutory.
6. Statutory bodies should be regularly inspected by the CQC or, other appropriate body, to ensure that training of professionals working in mental health services addresses issues of racial bias and cultural competence.
Whilst it will take time to eliminate racial discrimination and introduce greater inclusivity into Britain's mental health services, there are a number of charities and organisations who work exclusively to support Black mental health. Find out more in the Wellness section of our magazine.
Ms Esther Thomson