Feature

Subject: psychiatry. Diagnosis: racist

The psychiatric profession is failing to come to terms with Britain’s multiracial society, says S P Sashidharan, and a disproportionate number of black people are being kept in mental institutions, mostly under coercion

Black people in Britain, especially people of Afro-Caribbean origin, are far more likely to be admitted to a mental hospital than white, British-born people. What is even more alarming is the evidence of a five to 10-fold excess of black people being diagnosed as schizophrenic. It is estimated that any black person admitted to a mental hospital in England for the first time has a one-in-two chance of being diagnosed as schizophrenic, while a native-born white person is considered to be schizophrenic in only one-in-six or seven admissions.

What is the explanation for this? Conventional psychiatric thinking maintains that black people in Britain, particularly Afro-Carribeans, are vulnerable to schizophrenia. But such a conclusion inevitably raises more questions about the role and function of psychiatry in relation to black people than it does about the causes of mental illness. It can be argued that psychiatry accepts the theory of ethnic vulnerability to mental illness only to avoid a close scrutiny of institutional factors that influence clinical practice.

The methodological shortcomings of many of the studies that suggest an increased risk of schizophrenia among black people are commonly overlooked. Evidence from many studies suggests that diagnosis of schizophrenia is likely to be more unreliable and less specific in black patients than among white patients. And misdiagnosis of schizophrenia accounts for some, if not all, the excess Afro-Caribbean admissions to psychiatric hospitals.

Using an alternative interpretation, such evidence indicates that classifications of mental illness are not objective but are derived from white European culture, and so are deficient and misleading if used to categorise and describe the experience of non-European people.

The clinical encounter between a white European psychiatrist and a black person in a European setting is fraught with difficulty. There may be a serious distortion in the clinical assessment and its outcome, and there is a reluctance to consider the differences between the experience of black and white patients, before and after they cross the threshold of the mental hospital.

Black people are more likely than their white counterparts to have been brought into hospital against their wishes by the use of sections of the Mental Health Act. It is estimated that while 20% of all psychiatric admissions in Britain are made under the act, for black patients the equivalent figure is over 60%.

Recent studies of the use of section 136 of the act (which gives the police the power to remove a person from a public place for assessment for up to 72 hours, if mental disorder is suspected) show that it is used more often for black people. Within mental hospitals, black patients are more likely than white patients to be forcibly treated against their wishes and detained in secure facilities. Overall, there is a reliance on pharmacological treatment.

Black people have a predominantly negative view of psychiatry. There can be no question that the mistrust and suspicion thus created compounds some of the problems within hospitals and in other clinical situations. But psychiatry’s response to the difficulties black people experience in relation to psychiatry is to blame it on black people themselves.

The failure of conventional psychiatry both to recognise the historical legacy of racism, and to respond creatively to the fundamental critique of it function, has led to the re-emergence of the racial politics within the professional domain. As a result, the black community is becoming increasingly uncertain about the ability of professional psychiatry to produce relevant answers and solutions.

An alternative agenda of needs and priorities in mental health is emerging from within the black community, and the strength of voluntary initiatives in this area is testimony to this. Over the last two years the number of black groups concerned with mental health issues has increased substantially. Such voluntary projects are initially marginalised by the profession. There is increasing awareness among such groups that culturally-modified forms of conventional psychiatric treatment do not meet the needs of black people. Neither do they confront the fundamental problems of psychiatric practice.

A national conference held in Autumn 1988 formulated a much more radical critique of the ideology of psychiatry, and a National Black Standing Conference was inaugurated. It is initiatives such as these that will influence the way in which the psychiatric profession addresses the question of race in its practice.