The United Nations' Special Rapporteur for health called for a 'revolution' in mental health care in her report to the Human Rights Council last month. Dainius Pūras highlighted how damaging the biomedical model of treatment has been and it speaks volumes to the black British experience of psychiatry. It could not have come at a better time, as the Department of Health prepare for a public consultation on the 'first new Mental Health Bill for 30 years'.
The proposed change in legislation comes on the back of the election pledge by Prime Minister Theresa May to introduce the most wide raging reforms in this sector for a generation. It was accompanied by a commitment to reduce the disproportionate use of force against black people and other minority groups detained under the Mental Health Act and other custodial settings.
Death following restraint
The unbalanced use of the Mental Health Act against black people of African descent is well documented. The seminal David Bennett Inquiry report – produced following the tragic death of the 39-year-old musician in 1998 after he was restrained by up to five members of staff – called for discrimination within mental health services to be addressed.
Central to this inquiry report was the call to address the disproportionate use of this Act against black people and the levels of coercion that they are subject to. Although this has received very little attention of late, it remains a pressing issue that urgently needs to be addressed.
In stark contrast, extensive media coverage has been given to the 'Social Epidemiology of Psychoses in East Anglia (SEPEA)', a study asserting that black people are at greater risk of developing psychotic disorders than their white counterparts. It seeks to justify the way that the Mental Health Act has been used against more than three generations of black Britons.
It is concerning to note that no scrutiny – or reference even – is made in this study to the fact that the diagnostic tool used in psychiatry is discriminatory. The purported higher rates of psychosis among black people cited in this study is of diagnosis not incidence.
This is fundamental because the high rates of labelling black people of African descent with a diagnosis of psychosis does not represent a real finding, rather an indication of bias in diagnostic practice. However, it is on this basis that calls are being made for further research in the field and policy interventions are being developed.
Ethnic bias in attribution of risk
The absence of any reference in the 11-page SEPA study to the ethnic bias in both diagnosis and attribution of risk within psychiatry, which has been widely acknowledged for decades now, is a serious omission, particularly in light of the number of international human rights bodies who have raised the way that the Act is used against black British people as an issue of concern.
This is what urgently demands scrutiny and wholesale reform, particularly in light of the damaging impact that the misdiagnosing of black Britons has had on three generations of people from the UK's African Caribbean communities.
It has been known for some time now that state coercion rather than care typify the black patient experience. Psychiatric services are designed and commissioned in such a way that the mental health needs of black people are met with a forensic response from psychiatric services rather than a holistic therapeutic response. State violence has become the norm for this group, both while detained on locked wards as well as when they are out on release from hospital and living in the community. This is what has to change.
PM concerns over coercion
Prime Minister May, when she was Home Secretary, spoke out about her concerns about the levels of coercion being used against detained patients in a joint Home Office and Black Mental Health UK (BMH UK) summit on policing and mental health.
The Council of Europe's human rights committee review of the UK's human rights record expressly called on the British Government to address the institutional racism within mental health services faced by black people of African descent who are detained in this system.
Also the United Nations Committee on the Elimination of Racial Discrimination (CERD), in their final country report, in 2016, also called on the UK to address the disproportionate way that the Mental Health Act is used against black people of African descent.
International human rights bodies have made it clear that there is a need to address what the UN have called 'the outdated practices that violate human rights,' in mental health care.
Central to this is the pressing need for psychiatry to recognise the limits of its current approaches and acknowledge that diagnoses are not identified objectively; that they have no biological markers, and are not referenced by any external criteria. Rather, they are based to a large extent on the perceptions that practitioners have about people.
If the institutional racism in mental health services and the disproportionate levels of coercion meted out to black people in these settings is to be addressed, the UK's commitment to reform the Mental Health Act needs to be based on the wholesale reform of the diagnostic tools used in psychiatry.
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Matilda MacAttram is Director of Black Mental Health UK (BMH UK), Fellow, United Nations Working Group of Experts on People of African Descent.
i) Gov.uk (2014) Home Office and Black Mental Health UK, Policing and Mental Health Summit, https://www.gov.uk/government/speeches/home-secretary-at-the-policing-and-mental-health-summit