According to a 2001 report by the World Health Organisation, one in four people around the world will suffer from mental health problems at some point in their life. By 2020, mental disorders are expected to rank second behind heart disease as the most common illness in the world.

This disturbing pattern is reflected in the UK with a recent survey indicating that almost one in six adults have a neurotic disorder (such as depression, anxiety, phobias, etc.), while one in 250 has suffered from a psychotic illness (such as schizophrenia or delusional disorder).

The figures above will make worrying reading for most people. There is something uniquely disquieting about the notion of mental illness, which means that regardless of greater public awareness around the issue, popular discourse is still steeped in the language of the asylum. To admit to having mental health problems is to confess to being mad, to being a mentalist.

It is the social stigma attached to mental illness that often discourages people from seeking appropriate help early on. As such, it is vital that mental health services do all they can to inspire public confidence – to convince them that they will be treated fairly and can expect some kind of positive outcome from putting their minds in the hands of the professionals.

However, according to a report published by the Sainsbury Centre for Mental Health, the relationship between black communities and mental health services is characterised by fear and mistrust, with black people reluctant to seek help from a service they see as punitive and racist. This is all the more alarming when you consider the large body of research literature suggesting that race has a powerful influence on risk of mental illness, with studies consistently reporting a higher incidence of schizophrenia and psychotic illnesses in black than white populations in the UK.

Dr Kwame McKenzie of London’s Institute of Psychiatry sees racism as aetiologically important in the development of mental illness. Writing in a January 2003 edition of the British Medical Journal, he identified racial discrimination as a major public health issue. Indeed, a 2002 survey of Caribbean, African and Asian people found that those who had experienced a racist attack in the preceding year were nearly 3 times more likely to be suffering from depression and 5 times more likely to be suffering from psychosis.

Both race and ethnicity are associated with differential levels of social deprivation, leading some to interpret reported differences in rates of mental disorder as the result of socio-economic inequality rather than racism per se. However, in a post-Macpherson world, where the notion of ‘institutional racism’ is finally acknowledged, it is surely obvious that racism and social inequality are indivisible – they feed off one another creating a web of social exclusion that seems to put black people at greater risk of mental illness than their white counterparts.

Or does it? The vast majority of research into race, ethnicity and mental illness has been based on contact with treatment services, reflecting behaviour when ill, rather than illness itself. In 2000, the Survey of Ethnic Minority Psychiatric Illness Rates (EMPIRIC) – a community-based epidemiological study – reported a much smaller inequality than traditionally found. Though the rate of psychosis in the black Caribbean group in the study was twice that of the white group, the difference was not statistically significant. They concluded: “Since the concepts of ‘Western psychiatry’ are common to all research approaches, this suggests that even if Black Caribbean people are more vulnerable to psychotic illness, they are also treated differently in the UK.”

It is this differential treatment of black patients by mental health services that is of concern to the staff at the Sainsbury Centre for Mental Health, and that informs their 2002 publication Breaking the Circles of Fear. David Robertson, one of the authors of the report, says: “It has to do with the way in which risk is assessed, and the way in which black people with mental health problems are judged…people aren’t able to get the care they require before they go into crisis.”

Risk assessment is now an integral part of the job of psychiatrists and psychologists, a job made harder by hysterical media coverage of the rare – but dreadful – instances when mentally ill patients commit serious violent crimes. It is under such conditions that mental health professionals are prone to overestimate the dangerousness of black patients, perhaps influenced by the stereotype of the ‘Big, Black and Dangerous’ individual who they fear might walk out of the hospital or doctor’s surgery and commit a serious – and high profile – offence. Studies comparing black and white patients have shown that black patients are perceived to be more dangerous, despite lower ratings of psychopathology.

This misperception of the risk of violence posed by black people is thought to underlie the over- representation of African Caribbeans in psychiatric services. Moreover, it seems to underpin the large body of research indicating an experience of mental health services for black people in the UK that is frequently negative, inadequate and overwhelmingly coercive.

There is evidence stretching back over 3 decades showing that black Britons are more likely to be admitted to hospital with a first diagnosis of schizophrenia, more likely to be subject to police involvement in hospital admission, more likely to be detained in locked psychiatric wards, and their treatment more likely to be over-reliant on high doses of psychotropic medication and physical measures such as electro-convulsive therapy (ECT). Conversely, they are less likely to receive psychotherapy, psychological treatments and counselling.

Jacqui Sealy is an advocacy worker with the Mental Health Shop and works with African and Caribbean people in the Leicester area: “Men generally, and possibly African Caribbean men in particular, may not come for help early for fear of being stigmatised. More importantly, many may already have experienced poor services in the past.”

Thus, black people suffering from mental health problems find themselves in a classic Catch-22 situation. They are reluctant to approach psychiatric services for fear that they will be labelled, medicated and incarcerated – some may feel compelled to ‘self-medicate’ using illegal drugs or alcohol. Inevitably, their condition deteriorates and they ultimately reach crisis point, provoking the very coercive responses from services that they fear. This is the downward spiral – the Circle of Fear – that David Robertson and his colleagues at the Sainsbury Centre have been trying to break.

While a lack of funding and of effective communication are perennial problems, attempts are being made to address the system’s failings on a local and national level. In June 1997, five leading UK mental health charities combined to issue a joint policy statement on race and mental health, while the government has published a National Service Framework for Mental Health pledging to ensure a ‘culturally appropriate’ service .

However, Robertson feels that this is not the correct approach: “It is not about people’s culture – it is about inequality. Culture debates give rise to stereotyping, and a very static way of thinking about culture. There is too much emphasis on cultural differences rather than cultural similarities – you don’t need cultural awareness to treat someone with dignity and respect.”

The Sainsbury Centre report surveyed over 200 black service users, carers, professionals and police, and made 15 key recommendations aimed at reintegrating black service users, promoting mental health in the black community, supporting users and carers, and enhancing the infrastructure of the black community generally, to enable it to become more self-supportive.

“We have set up an implementation team focusing on 6 areas – leadership, workforce development, capacity building, supporting service users, families and carers, research and evaluation.” The research and evaluation aspects are particularly important, says Robertson. “We don’t want this to be another report that just sits on the shelf – we are looking to go out into the community and follow up on the work we have done.”

By encouraging closer links between mental health services and the black community through gateway agencies and black voluntary organisations, the team behind Breaking The Circles Of Fear have been trying to open lines of communication that have long been disrupted by mistrust and misunderstanding. And by involving service users and carers in their work, they have allowed them to feel that they are more than mere bystanders, waiting for the powers that be to decide their fate.

For many people such developments will come too late – people who have already found themselves at the sharp end of a mental health system that, despite good intentions, has often ended up mirroring the stereotypes, and compounding the pressures, which impact on the mental health of black Britons in wider society every day. Our public bodies have a responsibility to lead the way, to be brave enough to ask themselves if they are failing their clients and, if so, why? While the black community work to address their own fears and assumptions about mental illness and psychiatric services, it is high time for our mental health practitioners to indulge in a little self-reflection.

For further details, contact the Sainsbury Centre for Mental Health.

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