Review of the Mental Health Act fails to put ‘Race’ on its Agenda for change, but acknowledges the reality of institutional racism in the mental health system

Guest blog by Suman Fernando

The report by Simon Wessely, former president of the Royal College of Psychiatrists, is headed ‘Modernising the Mental Health Act’ and subtitled ‘increasing choice, reducing compulsion’. There is nothing we can object to in this report except that it fails to recommend any legislative changes at all that would reduce institutional racism. And this is in spite of assurances given by Simon Wessely earlier this year that race was on his agenda for the Review; and that - together with the Race Equality Foundation (REF) - ROTA submitted specific suggestions for such legal changes.

On more general matters, the recommendations for partial fusion of the Mental Capacity Act and Mental Health Act; the slight extension of powers of Mental Health Review Tribunals (MHRTs); and the ability of patients to challenge Care & Treatment plans via the MHRT system are welcome - all of these could help towards liberalisation of the Act as a whole if the Government implements the suggested changes. Incidentally the idea of an appeal to MHRTs vis-à-vis CTPs may have been taken from the suggestion in the submission by ROTA / REF of a tribunal-like body to hear appeals against diagnosis—a key factor in the way institutional racism plays out in sectioning.

this is a very psychiatric report. It is clearly written from within the profession of psychiatry. It is committed, for example, to doctrines of ‘diagnosis’ and ‘symptoms’ and signs of ‘mental pathology’ identified by psychiatrists as objective facts rather than judgments made by people (who are all too prone to hold culturally generated biases and misconceptions in forms institutionalised in the West). The report could have been written from the outside, from the stance of a dispassionate observer or more pertinently (since the main thrust of the legislation the report is supposed to review compulsion and deprivation of liberty allowed by the Mental Health Act) from the stance of the ethics of compulsion—or of people subjected to or forced to accept psychiatric decision-making. In this fundamental sense, this Review has a very different ‘feel’, to that carried out in 1999 by Genevra Richardson then a Professor of Public Law at Queen Mary University of London, who worked in collaboration with a team of twelve including (but not dominated by) a psychiatrist. By referring to the psychiatric nature of the report I mean (for example) how the report talks of ‘side-effects’ instead of consequences of actions by professionals; and equates ‘fear’ of (what used to be called) ‘the white coats’, with professionals’ fear of being ‘publicly shamed’ if they make mistakes. The report attempts to redress the psychiatric nature of the report by including within it a letter from a service user and carer group assuring the PM that they were consulted and an assertion by Simon Wessely that ‘during the lifetime of this Review, neither myself nor my three Vice Charis have experienced any political pressures to shape our decisions’ (p. 7). He ‘doth protest too much methinks’ (Hamlet by William Shakespeare). The account in the report of how the Review carried out its work I know to be far from accurate, having been a ‘special advisor’ to one of the groups.

The report is also pessimistic and disappointing in terms of its approach to issues of race and culture. The issue of racial inequality in our mental health system is well established. What concerns the function of the Mental Health Act is primarily the over-representation of BAME people among those sectioned and diagnosed as suffering from ‘schizophrenia’ and / or ‘psychosis’ (referred to in this report as ‘severe mental illness’). In a personal foreword under the heading ‘Ethnicity, Racism and Discrimination’, Simon Wessely quotes the consensus view that ‘the use of coercion is far greater in this population [people of black African and Caribbean heritage], finding its most painful expression in the statistic that those of black African or Caribbean heritage are over eight times more likely to be subjected to Community Treatment Orders than those of white heritage. In other words, too often and in too many areas the experiences of those of black African and Caribbean heritage is one of either being excluded or detained’ (p. 10). The foreword then goes on to express this extraordinary view: ‘So we have to accept the painful reality of the impact of that combination of unconscious bias, structural and institutional racism, which is visible across society, also applies in mental health care’ P. 10 italics inserted). The body of the report then fails to even mention institutional racism and the report itself totally ignores the various suggestions sent to Simon Wessely on how this particular problem can be alleviated.

Conclusions

The first question to be asked is whether this report would have had the same approach to ‘race’ if the victims of institutional racism had not been ‘black and minority ethnic’ people but a white minority / majority group?   The issue here is about white privilege and power. And the question arises as to how this systemic failure of an official report has come about.  Second, who carries responsibility for the failure of this report to have race on its agenda for change? The immediate responsibility of course lies with the person leading the Review but I suggest we need to look deeper. Perhaps, no one person is to blame but rather, blame lies in an (institutional) group culture that allowed it to happen—a professional culture or several professional cultures.  The lesson we need to take away is that when a government selects someone to conduct such a review it must take on board the systems of power and privilege in society at large. In common parlance this is often about institutional racism, so we are back where we started. This Review has raised false hopes in the minds and hearts of many black people. If we have moved on at all towards social justice by going through with it we have learned yet again as a society that the struggle for justice must continue until we all realise that ‘it is one thing to demand justice but something else to face the price that the powerful have to pay for it’  (Baldwin 1961). 

References

Baldwin, J. (1961) An interview with James Baldwin. Interview by Studs Terkel. (Almanac, WFMY Chicago), reprinted in The Last Interview and Other Conversations Brooklyn & London: Melville House. 

Modernising the Mental Health Act. Final report of the Independent Review of the Mental Health Act 1983. GOV. UK in PdF only. Available at: http:// www.gov.uk/dhsc.