Continuing divisions between black and minority ethnic (BME) groups still remain a significant social concern, with themes such as the higher likelihood of socio economic deprivation, lower levels of education and increase contact with the criminal justice system than their white counterparts still being highlighted (Bogg, 2010, pg66) It is also clear that these inequalities are inherent within the provision of mental health care services, with the Mental Health Act Commission (MHAC) reports continuing to highlight the higher rates of detention for BME groups under section 136 of the Mental Health Act 1983 (MHA 1983) (Bogg, 2010).
Racism has been argued to be a fundamental cause of inequalities in mental health care and racism within psychiatry derives from the traditions of the discipline, its history, ways of assessing and diagnosing, organisation and its involvement with the powers of state (Fernando, 2010, pg105). There are demonstrable differences in access to preventative care for majority and minority ethnic groups. This is partly because the structure of health services is often cast in the dominant culture’s mould (Bhui, 2002, pg 90). Racism in the provision of psychiatric services derives from the manner in which institutions are constructed and fashioned and the failure by most organisations to confront the inherent and historically determined racism (Fernando, 2010, pg105).
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Psychiatry, the doctrine concerned with disorders of the mind, is a western tradition developed in western cultures in conjunction with ideas surrounding race and power. The idea that BME groups had inferior brains or defective personalities was a common notion in the 19th century and these ideas were taken on board very easily and naturally by psychiatry and western psychology (Fernando, 2010, pg62). Historical perspectives illustrate the political and social motives which created the definitions of, and policies on mental health issues. The creation of mental health to support the social structure of the time can be best demonstrated by the case of draptomania, an ‘illness’ particular to slaves and whose classic symptom was the ‘irresistible urge to run away from the plantation (Ndegwa et al, 2003, pg90). This demonstrates the element of control issued through the ideas around mental health and the notion of inferior BME groups.
Racism is still thought to expressed and felt today in the provision of mental health care and other public services. Research into the structures and organisations of mental health services identified systems of inequalities based on race and is known as institutional racism. In the investigation of Stephen Lawrence’s death institutional racism was defined as ‘the collective failure of an organisation to provide appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviours which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethnic people (Macpherson, 1999). The report found institutional racism in many aspects of the Stephan Lawrence case, including the conduct of the investigation, the treatment of the family, the failure to recognize the murder as racially motivated and the lack of urgency and commitment in the investigation (Singh, 2007, pg363).
Since the publication of the Macpherson report institutional racism has been declared to be a problem in the UK National Health Service (NHS). A significant development into the NHS, especially its mental health services being branded as institutionally racist is the inquiry into the death of David ‘Rocky’ Bennett. An inquiry team was set up to examine the care and treatment that Rocky Bennett received before he died after being restrained by up to five nurses (Athwal, 2004). The inquiry report described the inequalities in mental health services faced by black and minority patients as ‘a festering abscess which is at present a blot upon the good name of the NHS (Norfolk, Suffolk and Cambridgeshire Strategic Health Authority, (2003) and attributed these inequalities to institutional racism.
It can, however, be problematic to use institutional racism to explain the circumstances of Bennett’s death. The failure to train staff in methods of safe restraint and prompt resuscitation cannot be seen as institutionally racist in itself unless some racist intention or process can be identified in this failure, since all patients could suffer as a consequence. However, if fears of black male patients’ inherent violence led to their being restrained more frequently and forcefully, then a racist effect could ensue. But in this case it is the assumption about black violence, rather than the failure in training that constitutes the racism in question. Furthermore assumptions about black violence are held by individuals rather than constituting a feature of the organisation (Bradby, 2010).
In 2005, in response to increase awareness of racial discrimination in the psychiatric system, the Department of Health introduced its BME mental health programme through the National Institute for Mental Health in England (Coppock et al, 2010, pg114). The programme aims to improve the mental health care of all people of BME status including those of Irish or Mediterranean origin and east European migrants (DoH, 2005). However, while this publication accepted most of the recommendation made by the inquiry into the death of Rocky Bennett’s death, it refuted the existence of institutional racism in mental health services. In doing so, it ignores the finding of the Macpherson Report. Such an approach fails to contextualize the various forms of direct and institutional racism in the wider society (Coppock et al, 2010, pg114).
‘Count Me In’ (2007) was a one day census of the NHS hospitals, private mental health hospitals, and learning disability units which contributed to the increasing evidence of ethnic differences in the treatment of mental illness (McKenzie et al, 2007). The survey of 32,023 inpatients on mental health wards in 238 NHS hospitals reported that 2 per cent of patients were from BME groups although they only represent 7 per cent of the population in the UK (MHAC, 2007). It is too simplistic and problematic to blame institutional racism for such a situation and whilst it is the case that Afro-Caribbean’s are over represented, other groups such as the Indian and Chinese communities are underrepresented. Such discrepancies indicate that there may be more to this than the issue of race and ethnicity (McLaughlin, 2007).
Nevertheless, it has been argued that a lack of understanding of cultural diversity in the experience and expression of distress leads to the reinforcement of cultural stereotypes which can result in misdiagnosis and negligent care (Coppock et al, 2010, pg113). The Ritchie inquiry into the care and treatment of Christopher Clunis is another high profile inquiry that found the collective failures in psychiatry to an individual from a BME group (Singh, 2007). Many shortcomings were recorded about the institutional racism that was identified, for example, Clunis’ first visit showed that the ‘opportunity for early diagnosis and possibly effective treatment was lost’ (Ritchie, 1994, pg14) to a desire by social workers ‘not to stigmatise a patient, or label him in any way as a violent or difficult person which was felt might work to his disadvantage’ (Ritchie, 1994, pg19).
The enquiry made it clear that there was a tendency among staff repeatedly to ‘postpone decision or actions when difficultly was encountered or perhaps because the patient was threatening and intimidating, and possibly because he was big and black’ (Ritchie, 1994, pg107). This report, it has been argued, reveals institutional racism in practice and demonstrates the risks that many from BME groups face within psychiatry of not being given the correct diagnosis and not being treated assertively enough, simply because of their ethnicity (Singh, 2007).
Accusations of institutional racism would appear to be well founded and disparities reflect the way health services offer specific treatments of care pathways according to racial group, and therefore seem to satisfy the well established and widely known definition (McKenzie et al, 2007). However, a closer look at the issue shows the reality to be more complex than it is often reported, and also highlights the danger of pathologising whole communities under the guise of therapeutic aid (McLaughlin, 2007). The issues argued by Mckenzie and Bhui (2007) that presupposes that treatments are in reality offered on the basis of racial group disallows the possibility that ethnic differences might exist because of other societal factors, which may not be within the control of health services (Singh, 2007). More over it does not consider the possibility that care pathways are not always offered by health services but are sometimes chosen, and sometimes imposed upon patients by legal processes, outside the control of healthcare services (Singh, 2007).
However, Mckenzie and Bhui argue that acknowledging the existence of institutional racism can lead to tackling the causes of these racial disparities. Delivering race equality may training may have some impact on disparities in involuntary admissions but because such admissions reflect the combined actions of the criminal justice system, social services and education, a strategy based in mental health services alone is unlikely to be sufficient (McKenzie et al, 2007).
Institutional racism and oppressive practices have resulted in increased funding of research into the amount of mental illness amongst ethnic minorities. In the UK, the voluntary sector has emerged as a provider in response to the inflexibility of statutory services and has been charged with the responsibility to develop better services, while the statutory sector remains not only unattractive but aversive to BME service users (Bhui, 2002, pg139). The strength of specialised services lies in the mandate from service users and the commitment of the voluntary sector and the practitioner’s interest in culturally competent mental health care provision (Bhui, 2003). In contrast, some argue that, whenever BME groups are the focus of discussion, it immediately focuses on the idea of the ‘separate’, ‘different’ and ‘them’ being not part of ‘us’ and therefore requiring ‘special’ attention, outside of the provision of mainstream services (Bhui, 2003). Rather than promoting the needs of BME service users, there is a danger that specialist services can marginalise people from minority ethnic communities even further (Lester et al, 2010, pg193).
However, specialist services already exist and are now being adopted in statutory services engage those most disenfranchised by existing models of care. Existing services as a whole do not offer a system of care in which BME groups can expect to receive the least coercive treatment (Bhui, 2003). On the other hand, some commentators argue that the solution for the current problems in the provision of mental health care, must involve the mainstream of psychiatric practice rather than marginal initiatives that emphasise further segregation of minority needs (Bhui, 2003).
For many commentators, the way forward may actually require a dual approach; working inside mental health services to make them more appropriate for people from minority ethnic communities, while at the same time working outside public sector mental health services to build capacity within black and minority communities and the voluntary sector for dealing with mental ill health (Lester et al, 2010, pg193). To ensure that culturally sensitive services become a mainstream feature of mental health services rather than an optional extra, the majority of commentators emphasise the central importance of training (Lester et al, 2010, pg194). However, by focusing inappropriately on culture and ethnicity at the expense of sound clinical judgments, we risk offering poorer rather than better care to patients from minority ethnic groups (Singh, 2007).
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