RACE AND CULTURE ISSUES IN MENTAL HEALTH THOUGHTS ON IDENTITY

1. �RACE� AND CULTURE ISSUES IN MENTAL HEALTH&THOUGHTS ON IDENTITY Suman Fernando www.sumanfernando.com European Centre for Migration & Social Care (MASC), University of Kent Department of Applied Social Studies London Metropolitan University There are two sections to my talk, the first addressing the overall topic for today and the second referring back to yesterday, when we had all those wonderful talks. � Mental Health, Race and Culture Issues around race and culture in mental health services in the UK have been highlighted in the literature since the early 1980s � the main concerns being around admission to psychiatric institutes and compulsory detention (�sectioning�) under the Mental Health Act (e.g. see McGovern and Cope, 1987; Moodley and Thornicroft, 1988; Coid et al. 2000) and the diagnosis of schizophrenia. The main thrust of these issues is well known (Fernando, 1988, 2003). There are two sections to my talk, the first addressing the overall topic for today and the second referring back to yesterday, when we had all those wonderful talks. � Mental Health, Race and Culture Issues around race and culture in mental health services in the UK have been highlighted in the literature since the early 1980s � the main concerns being around admission to psychiatric institutes and compulsory detention (�sectioning�) under the Mental Health Act (e.g. see McGovern and Cope, 1987; Moodley and Thornicroft, 1988; Coid et al. 2000) and the diagnosis of schizophrenia. The main thrust of these issues is well known (Fernando, 1988, 2003).

2. ETHNIC ISSUES IN UK Black / Ethnic Minorities more often: Diagnosed as schizophrenic Compulsorily detained under M.H.Act Admitted as �Offender Patients� Held by police under S. 136 of M.H.Act Transferred to locked wards Not referred for �talking therapies� Given high doses of medication Sent to psychiatrists by courts Ref: Fernando, S. (2009) �Inequalities and the politics of race in mental health�, in S. Fernando and F. Keating , Mental Health in a Multi-ethnic Society second edition, Routledge, London and New York Slide: Ethnic issues in UK � But these problems are not confined to psychiatry. Counselling services and psychology services too have them - more hidden than in psychiatry � and certainly getting less publicity mainly I think because they do not have the same obvious power for example in not having legal powers to force treatment. But the problems are there. Detailed ethnic statistics on counselling and psychotherapy (for example on what clients actually think about them) are few and far between. However, we know that (in the US at any rate) there are high drop out rates (Rosenthal and Frank, 1958) and low acceptance rates (Yamamoto et al. 1968) of black clients, the latter recorded as being to do with �ethnocentricity� of the therapists (Yamamoto et al. 1967) � which could as easily be called unconscious racism. In the late 1980s a trainee in Leicester (UK) wrote in to the Psychiatric Bulletin saying that while in the acute ward of her hospital she encountered many black patients in the psychotherapy unit there were none (Campling, 1989). I initiated one of the early ethnic monitoring exercises in the psychiatric unit I was working at to find very similar figures. [circulated the figures but fell on deaf ears.] � I have presented statistics from UK because I am familiar with these but also because in the UK we seem to collect a lot of ethnic statistics. Many other European countries do not collect these statistics and I do not think Ontario does either. Anecdotal information suggests that, if anything, the inequities may be much worse in mainland Europe than they are in UK � and perhaps the same may apply to North America too. A recent book from the USA, Protest Psychosis; How Schizophrenia became a Black Disease by Jonathan Metzl (2009) shows how in the USA, fears of black militancy in the 1960s, together with radical shifts in diagnostic habits codified in DSM, converged to construct a situation where the use of schizophrenia diagnosis for African Americans came into play on a large scale during the civil rights movement (essentially for social control) � and this over-representation of African-Americans as �schizophrenics� continues. � Coming back to psychiatric studies, there have been many epidemiological studies around the issues of �sectioning� (i.e. compulsory admission to treatment) and of schizophrenia � talked about as �the problem of over-representation�. And there has been quite a lot written about the reasons for all this - not least by me - but, politically speaking, we have not got very far in enabling this written work (�research� one could call it) to be taken seriously enough to bring about change, to make things more equitable � �race� equality� is the term used. Or it may be that the sort of change that should be made is just not acceptable politically and socially � and I dare say professionally probably because it is felt as striking at professional competence. [There talk of course about cultural sensitivity and even �cultural formulation� approach of US is copied in UK.] � On the other hand there have been some high profile deaths (and many low profile ones) in psychiatric custody of black people, the latest high profile one being that of Rocky Bennett (Norfolk, Suffolk and Cambridgeshire Strategic Health Authority, 2003). [Norfolk quarrel with white patient � transferred to locked ward � attacked a nurse �why me� � held down by 6-8 nurses � died of suffocation.} � It we turn to what service users make of this (he experience of people who use mental health services) a recent report sums it up (Keating et al. 2003).Slide: Ethnic issues in UK � But these problems are not confined to psychiatry. Counselling services and psychology services too have them - more hidden than in psychiatry � and certainly getting less publicity mainly I think because they do not have the same obvious power for example in not having legal powers to force treatment. But the problems are there. Detailed ethnic statistics on counselling and psychotherapy (for example on what clients actually think about them) are few and far between. However, we know that (in the US at any rate) there are high drop out rates (Rosenthal and Frank, 1958) and low acceptance rates (Yamamoto et al. 1968) of black clients, the latter recorded as being to do with �ethnocentricity� of the therapists (Yamamoto et al. 1967) � which could as easily be called unconscious racism. In the late 1980s a trainee in Leicester (UK) wrote in to the Psychiatric Bulletin saying that while in the acute ward of her hospital she encountered many black patients in the psychotherapy unit there were none (Campling, 1989). I initiated one of the early ethnic monitoring exercises in the psychiatric unit I was working at to find very similar figures. [circulated the figures but fell on deaf ears.] � I have presented statistics from UK because I am familiar with these but also because in the UK we seem to collect a lot of ethnic statistics. Many other European countries do not collect these statistics and I do not think Ontario does either. Anecdotal information suggests that, if anything, the inequities may be much worse in mainland Europe than they are in UK � and perhaps the same may apply to North America too. A recent book from the USA, Protest Psychosis; How Schizophrenia became a Black Disease by Jonathan Metzl (2009) shows how in the USA, fears of black militancy in the 1960s, together with radical shifts in diagnostic habits codified in DSM, converged to construct a situation where the use of schizophrenia diagnosis for African Americans came into play on a large scale during the civil rights movement (essentially for social control) � and this over-representation of African-Americans as �schizophrenics� continues. � Coming back to psychiatric studies, there have been many epidemiological studies around the issues of �sectioning� (i.e. compulsory admission to treatment) and of schizophrenia � talked about as �the problem of over-representation�. And there has been quite a lot written about the reasons for all this - not least by me - but, politically speaking, we have not got very far in enabling this written work (�research� one could call it) to be taken seriously enough to bring about change, to make things more equitable � �race� equality� is the term used. Or it may be that the sort of change that should be made is just not acceptable politically and socially � and I dare say professionally probably because it is felt as striking at professional competence. [There talk of course about cultural sensitivity and even �cultural formulation� approach of US is copied in UK.] � On the other hand there have been some high profile deaths (and many low profile ones) in psychiatric custody of black people, the latest high profile one being that of Rocky Bennett (Norfolk, Suffolk and Cambridgeshire Strategic Health Authority, 2003). [Norfolk quarrel with white patient � transferred to locked ward � attacked a nurse �why me� � held down by 6-8 nurses � died of suffocation.} � It we turn to what service users make of this (he experience of people who use mental health services) a recent report sums it up (Keating et al. 2003).

3.  �CIRCLES OF FEAR� REPORT2003 SERVICES Too coercive, lack respect, and not integrated with community PATHWAYS Do not involve primary care and community based facilities DISCOURSE Models of �mental illness� do not acknowledge cultural diversity SERVICE USER AND CARER INVOLVMENT Poor or non-existent BLACK-LED INITIATIVES Not valued or supported properly Ref. Keating et al., (2003) Breaking the Circles of Fear. A Review of the relationship between mental health services and African and Caribbean communities. (London: Sainsbury Centre for Mental Health). Slide: Circles of fear report � Today, in UK there is an acceptance of serious problems, but little headway in getting any change. In an effort to understand what is going on, my approach over the years has been to first ask the question how we have got here. What the lay of the land may be, the background to all this, the broader scene. For one thing the race statistics in mental health services resemble, not statistics in other parts of health but resemble those of (a) disproportionate exclusion from school of black boys (for difficult behaviour) and (b) black over-representation in prisons (summarised by Fernando, 2009). In fact, although �culture� may well be involved at some level in mental health field � as may be social class and poverty - it seems mostly a �race� issue. � What I shall do in this talk, is to summarise briefly something of what I have written and spoken about for some years and then try to draw some conclusions. Slide: Circles of fear report � Today, in UK there is an acceptance of serious problems, but little headway in getting any change. In an effort to understand what is going on, my approach over the years has been to first ask the question how we have got here. What the lay of the land may be, the background to all this, the broader scene. For one thing the race statistics in mental health services resemble, not statistics in other parts of health but resemble those of (a) disproportionate exclusion from school of black boys (for difficult behaviour) and (b) black over-representation in prisons (summarised by Fernando, 2009). In fact, although �culture� may well be involved at some level in mental health field � as may be social class and poverty - it seems mostly a �race� issue. � What I shall do in this talk, is to summarise briefly something of what I have written and spoken about for some years and then try to draw some conclusions.