Race and mental health: there is more to race than racism
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38930.501516.BE (Published 21 September 2006) Cite this as: BMJ 2006;333:648All rapid responses
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‘Race and mental health: there is more to race than racism’
by
Swaran p Singh, Tom Burns
All quotes drawn from the piece
A Reply:
Racism
As the central argument of the article is the inappropriateness of racism/institutional racism as the main explanation for over-representation of particular Black and Minority Ethnic (BME) communities within the coercive end of the mental health system, the author’s understanding of the terms ‘racism’ and ‘institutional racism’ is critical. Unfortunately no definition or explanation of these terms is provided. The reader is therefore left to infer the author’s take on racism from how it is used. This is where the arguments of the authors begin to falter.
The authors state the following: “Construing racism as the main explanation for the excess of detentions among ethnic minorities adds little to the debate and prevents the search for the real cause of these differences. . .such a vague and meaningless, yet insulting accusation [of institutional racism] contrasts with the real attempts over the past 50 years to move away from mystifying jargon that cannot be interrogated. It devalues the thoughtful research that has been conducted to better understand these problems . . . it distracts both professional and minority communities from trying to understand these very real differences”. This view that racism and institutional racism are inappropriate concepts subverting proper understanding of issues of ethnic disporoportionality betrays a fundamental misunderstanding of the terms which leads to the author’s view that they are ‘vague’ and ‘meaningless’. The fact is that racism is about the impact of socially rooted racialised power differences in all areas of human relations. Institutional racism is about how these power differences are mediated through established organisation processes that orient the behaviours of individuals within institutions. It is about racial discrimination as a social norm that does not necessarily require explicit acknowledgement or individual intention for its influence to be exercised. Indeed, the denial or dismissal of institutional racism desensitises people to its existence, thereby reducing the possibility of remedial action.
Understood properly, it is clear that psychiatry is not ‘accused’ of racism with a view to provoking the defensive reaction evident in the article. Nor is racism proffered as a means of dismissing other factors or forms of explanation that coalesce to generate ethnic bias within the mental health system. The point is to realise how racism rooted in British social history and a functional dynamic within British institutions influences the perceptions, tools and techniques of clinicians through the legacy of professional training and practice. This cuts to heart of how notions of illness and wellness are framed – the schema through which clinical judgements and conclusions are arrived at.
Psychiatry
The “two main grounds” proffered by the authors of those advocating racism as an explanation for the higher rates of diagnosed psychosis in second generation African-Caribbean patients are as follows:
i/ ‘that the diagnosis are mistaken, stemming from “Eurocentric” diagnostic practices . . “
ii) ‘ . . . the clinical response is powerfully influenced by racial stereotypes.
The lack of a full grasp of the nature and operation of racism has caused the authors to alight on these factors as the main facets of the counter-argument. In truth, these factors are outcomes of more fundamental processes that should be the focus of a fuller, more meaningful analysis of the ethnic disproprotionality in mental health. These processes relate to the way in which properly functioning ‘non-mistaken’ psychiatric practice itself generates racially varied outcomes. Also, how racial stereotypes as social norms influence all aspects professional perception and clinical interactions that lead to the clinical response. The article fails to sufficiently ‘unpack’ both the issues themselves and the arguments its seeks to challenge.
Locating clinical practice within this broader context clarifies the position referred to by the authors: “Using highly structured and validated research diagnostic assessment by independent raters, these studies have consistently confirmed high rates of psychosis in the African-Caribbean population (particularly second generation immigrants) and also not found any raised rate of misdiagnosis”. As the statement actually implies, it is the discriminatory nature of ‘normal’, ‘properly functioning’ psychiatric practice, for reasons already discussed, that is the real issue. The fundamental flaw of the article is the implicit assumption that proper clinical practice equates to non-racist practice. The terms of the debate are therefore about the degree to which psychiatry ‘gets it wrong’ for ‘racist’ reasons – the authors postulating that it is not nearly to the degree claimed by others. Whilst not entirely dismissing the ‘getting it wrong’ thesis, the truth is that the critique of racial bias within psychiatry is more about its ‘normal functioning’ - the themes, perspectives, methods and general received wisdom informed by racialised precepts. It is not enough to refer to these forms of explanation as “vague, meaningless, yet insulting accusations’.
By manoeuvring the discussion away from the subtle, complex, challenging reality of institutional racism implicit and explicit in psychiatry, the authors fall foul of their own critique, inappropriately weighting particular factors which contribute to overrepresentation at the expense of others.
Interpretations of evidence
Having dispensed with racism as a prime explanation of disparity, the authors need to provide “perfectly reasonable explanations for why the rates and manner vary between different ethnic groups”. Research is quoted showing “rates of psychotic disorder are high not just among the African-Caribbean community in the UK, they are high for all immigrant groups globally”. “Lower rates of referral from general practitioners and higher referrals from the criminal justice system”. “greater stigma of mental illness in the African-Caribbean community [acting] as a barrier to early help-seeking behaviour”. “unemployment, living alone, low levels of social support non-compliance with medication”.
It is unclear why the authors are prepared to accept such a diversity of factors as contributing to disporportionality, whist rejecting institutional racism within psychiatry as a factor of similar significance. Indeed, it is unclear why the authors seek to present these factors as “perfectly reasonable alternative explanations” [emphasis added]. The dichotomy is a false one. For many years campaigners in this area have integrated the various explanations referred to by the authors into a compressive understanding of disporportionality within mental health. The artificial separation of explanations posited by the authors and racism (apparently posited by others) is further evidence of the author’s misunderstanding of the debates about institutional, racism within psychiatry.
Contradictions
Developing the theme of the false dichotomy between racism and other explanations (community-based stigma around mental health, social differences etc.), it seems that the authors are themselves aware of the limitations of their own position. Despite the general thrust of the article, in their concluding comments the authors state that “There are real ethnic inequalities in mental health care, which deserve closer attention and remedial action. It is likely that racism, combined with economic disadvantage and social exclusion, contributes to poor experience of psychiatric services for minority communities.” Measured against points made earlier in the piece, it seems the authors are guilty of overstating their central premise of rebutting the ‘institutionally racist psychiatry’ explanation. Understanding racism as part of a wider complex that leads to inequality is a fundamentally different position than; “construing racism as the main explanation for the excess of detentions among ethnic minorities adds little to the debate and prevents the search for the real cause of these differences”. The issue then seems to boil down to the word ‘main’ – whether institutional racism is a main or peripheral explanation for the disparity. The precepts and practice of psychiatry and the experiences of those using mental health services imply that it is the main explanation. It is an area worthy of further exploration.
Conclusions - Making sense of it all
Whilst the authors eventually make the case that racism is a piece of the puzzle, overall there is a clear attempt to shift the terms of the debate away from institutional racism. Reasons given for this are themselves questionable. Rather than questioning the integrity of institutional racism from a informed, developed explanation of the concept, the authors refer to damage done to users of mental health services by establishing negative expectations of services, and the damage to staff who feel demoralised, undervalued and blamed for being racist. The implication is that ‘better to deny the reality if awareness of it breaches a particular threshold of comfortability and challenge’. One may infer that the avoidance of such challenge is the reason why, despite the acknowledgements at the end of the article, the authors make such a vigorous, concerted effort to expunge institutional racism within psychiatry as an explanation of ethnic disparity. Progress in this area will only be made from a premise that is cohesive and conceptually robust. Unfortunately the article fails on both counts.
Marcel Vige
Diverse Minds Development Manager at Mind
Co-Chair National BME Mental Health Network
Competing interests:
None declared
Competing interests: No competing interests
Editor - In their balanced and thought-provoking article, Singh and
Burns (1) make the point that although racism in society at large almost
certainly contributes significantly to mental ill health, unequal access
to mental health services and negative perceptions and experiences of
psychiatric care, psychiatry itself is no more likely to be racist than
any other societal institution. Thus there is no convincing evidence that
psychiatrists consistently misdiagnose psychosis, overuse tranquillising
medication or compulsorily detain patients in hospital under the Mental
Health Act according to patients' race or ethnicity.
Given that good psychiatric practice relys heavily on establishing
trust between patients and practitioners, to imply or assert that
psychiatry is racist until proved otherwise (2) does a disservice to those
who practice and those who need psychiatric care.
In the contentious area of management of violent behaviour associated
with psychosis, in my experience, psychiatric staff may be reluctant to
use appropriate assertive interventions (3) to help black or other
patients from ethnic minorities due to a fear of being accused of racism.
This issue is particularly relevant because there is evidence that
psychotic patients from such groups may present with higher rates of
violent behaviour. For example, in the AESOP study (4) of first episode
psychosis which was referred to by Singh and Burns (1), black patients
were twice as likely as white patients to show violent behaviour prior to
admisssion to hospital. Thus 12.6% (95% ci = 8.5-16.7) of 261 white
patients were recorded as violent, compared to 24.3% (95% ci = 18.1-30.5)
of 189 black patients. As the great majority of these patients had not
been admitted to psychiatric hospital before, increased violence before
admission clearly could not be explained by previous exposure to coercive
psychiatric inpatient management.
Although the increased incidence of violent behaviour in psychotic
black patients prior to admission could not account entirely for the
excess of compulsory admissions of black patients found in the AESOP study
(4), it is nonetheless likely to have had an important influence on the
the experiences and expectations, and most importantly on the subsequent
attitudes and behaviour of both patients and psychiatric staff alike.
One of the possible causes of increased violence in psychotic black
patients with little or no previous contact with psychiatric services
might be their experience of adverse discrimination in a racist society.
It is easy to envisage how, in a vulnerable group of people suffering from
psychosis, the negative attitudes engendered by these experiences might be
transferred at an early stage to the psychiatric services trying to help
them. This would serve to establish a pattern of mistrust and
disengagement which may be readily perceived as further evidence of racism
in psychiatry.
As Burns and Singh point out (5), the need is for 'good research
evidence' rather than 'ideology and political correctness' if prejudice
against providers of psychiatric services for black people is to be
avoided, whilst sustaining morale and therapeutic optimisim in a culture
of suspicion and blame, hopefully with the result of improving standards
of care for all (6).
(1) Singh SP, Burns T. Race and mental health: there is more to race
than racism. BMJ 2006; 333: 648 - 651
(2) Hollins SC, Moodley P. Racism in mental health. bmj.com, 13
October 2006
(3) National Institute of Health and Clinical Excellence. Clinical
guideline 25. Violence: the short-term management of disturbed/violent
behaviour in in-patient psychiatry settings and emergency departments.
February 2005. (www.nice.org.uk/CG025fullguideline)
(4) Morgan C, Mallett R, Hutchinson G, Morgan K, Fearon P, et al.
Pathways to care and ethnicity. 1: Sample characteristics and compulsory
admission. Report from the AESOP study. Br. J. Psychiatry 2005; 186: 281 -
289
(5) Burns T, Singh SP. Re: Racism in mental health. bmj.com, 17
October 2006
(6) Harrison-Read P. Prejudice against providers of psychiatric
services for black people. Br. J. Psychiatry 1997; 171: 582
Competing interests:
None declared
Competing interests: No competing interests
I agree with Sheila Hollins' comments.
The authors state that more research needs to be carried out on this
topic. But in his reply to Sheila Hollins' letter Professor Burns appears
to be rallying us behind his campaign to explain to the population that
everything was fine in this area.
The tone of the article suggests the authors' primary objective was
to express their feeling of irritation from any claim that institutional
racism might exist in our current practice. This can hardly be a way to
stimulate a balanced debate and sophisticated research in a controversial
and sensitive topic.
This article was written by 2 professors. An outsider can wrongly
regard this as the position of the profession. Therefore I think that the
president of the Royal College of Psychiatrists is right to, quite
frankly, distance itself from it, and to express her disagreement.
Competing interests:
None declared
Competing interests: No competing interests
The paper by Singh and Burns (1) has two major flaws. First, the
authors fail to understand the nature of institutional racism. For
example, McPherson’s definition refers to ‘discrimination through
unwitting prejudice, ignorance, thoughtlessness and racist stereotyping’
(2). Second, the authors take a simplistic approach to what ‘diagnosis’,
and hence ‘incidence’ of ‘mental illness’, means in psychiatry. The
categories (of diagnoses) we use have been constructed in a particular
socio-cultural context. Although sometimes useful for practical purposes
even in a multicultural society, ‘diagnostic categories are simply
concepts, justified only by whether they provide a useful framework for
organising and explaining the complexity of clinical experience’ (3). In
other words, diagnoses in psychiatry are not objective in the way diabetes
or hypertension may be. Since they are made ‘in areas and experience …
[where] human values are highly diverse’ (4), diagnoses are affected by
many influences incorporating ‘isms’ of various types. Institutional
racism – and indeed the influence of ‘culture’ on diagnosis - cannot be
understood by a review of medical-type research that the Department of
Health funded SPS to conduct. Mostly the methodology of such studies fails
to allow for bias and use cross-culturally problematic categories, such as
‘schizophrenia’ – an issue described by Kleinman (5) as ‘category
fallacy’.
Lee Jasper was right to identify institutional racism as the major
reason for Black African and Caribbean people being disadvantaged in
mental health services (6). The evidence for his claim stems from the
experiences of the users of our mental health services and arguments
presented in the literature (7). By its very nature such evidence does
not get translated easily into ‘scientific’ (sic) papers, but is depicted
(for example) in documentaries such as Whose Mind is it Anyway (8) in
which one of the authors (TB) features.
References
(1) Singh, S. P. & Burns, T. (2006) ‘Race and mental health: there is
more to race than racism.’ British Medical Journal, 333, 648-651
(2) Home Department (1999) The Stephen Lawrence Inquiry. Report of an
Inquiry by Sir William Macpherson of Cluny (London: The Stationery Office)
(3) Kendell, R. & Jablensky, A. (2003) ‘Distinguishing between the
validity and utility of psychiatric diagnoses.’ American Journal of
Psychiatry, 160, 4-12
(4) Dickenson, D. and Fulford, Bill (K. W. M.) (2000) In Two Minds. A
Casebook of Psychiatric Ethics. Oxford: Oxford University Press
(5) Kleinman, A. (1977) ‘Depression, somatization and the “new cross-
cultural psychiatry”’. Social Science and Medicine, 11, 3-10
(6) Macattram, M. (2006) Census reveals unprecedented levels of racism
within the NHS. 15 Dec 2005. National Black and Minority Ethnic Mental
Health Network.
www.bmentalhealth.org.uk/index.php?option=com_content&Task=view&id=46&It...
(accessed 1 August 2006)
(7) Fernando, S. (2003) Cultural Diversity, Mental Health and Psychiatry.
The Struggle against Racism (Hove & New York: Brunner-Routledge.)
(8) BBC (1995) Videos for Education and Training
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
Singh and Burns' paper is a well researched and thoughtful contribution to
this important subject. Their conclusions, including their comments on the
damaging effects of (inadequately substantiated ) allegations of
institutional racism, are balanced and moderate and in accordance with
common sense and clinical experience.
By contrast, the response from Hollins and Moodley is poorly
considered and hyperbolic. The suggestion that Singh and Burns' paper "
risks setting psychiatry back twenty years " is ludicrous. Nor can the
paper reasonably be described as " an attempt to deny that racism has any
influence at all on mental health or mental health sources (sic)".
Hollins and Moodley have chosen to write in their official
capacities, purporting to represent the Royal College of Psychiatrists,
but it is unlikely that their views are shared by more than a tiny
fraction of the membership of that body.
Yours faithfully
Ian G Bronks F.R.C.P.(Ed.), F.R.C.Psych.
Competing interests:
None declared
Competing interests: No competing interests
In their reply, it is heartening to note that Singh & Burns have
acknowledged the existence of racism in psychiatry. However, their
original analysis and comments give the unfortunate impression that there
had been some attempt to dilute the horrors of racism in psychiatry and
medicine, generally.
Competing interests:
None declared
Competing interests: No competing interests
In their response Hollins and Moodley seem highly critical of our
article but appear to have paid little attention to its actual content.
They start with the remarkable claim that we deny racism has any influence
on mental health. This despite our explicit expression of its importance
for the experience of ethnic minorities (“…deeply damaging to individuals
and communities…”) and its contribution to unequal access and poor
experience of mental health care. Even more remarkably they later quote
our concerns about racism (apparently unaware of their inconsistency) to
point out that we are not alone in advocating for good research and
appropriate service delivery – which we never claimed.
They criticise the main thesis of our paper (that the raised rates of
psychosis in ethnic minority groups are real and not the result of
misdiagnosis) yet remind us of the even greater rates in second generation
African-Caribbeans. Does this mean they accept the reality of the raised
rate of psychosis in ethnic minorities, and will they join us in efforts
to correct the persistent and corrosive charge of misdiagnosis?
Hollins and Moodley acknowledge that we make several observations
about the raised rate of compulsory detention but call us naïve for
singling out lack of family support as the sole reason. Had we done so it
would, indeed, have been naïve. However we focused on it as one of
several possible causes, one for which we now have good research data. We
believe taking evidence seriously is how to make progress in these
difficult and sensitive areas.
We are at a loss to understand the paragraph about biological
differences. The studies we have cited are clinical and epidemiological
and our conclusion is explicitly that a social, rather than genetic,
causation is more likely. We are, after all, both professors of social
psychiatry.
Whether the concept of institutional racism is helpful or not is open
to honest debate. Clearly we have our doubts. However the high rates of
psychosis in black ethnic minority patients is a real finding,
consistently repeated, and no longer open to reasonable doubt. It does not
indicate poor diagnostic practice and requires no sinister explanations.
The higher rates of compulsion are more complex. We do not propose a
single explanation but have presented good quality published research to
try and begin to understand it.
Hollins and Moodley fear that our paper ‘.. risks setting psychiatry
back twenty years…’. We doubt this and fervently hope not. Our fear is
that a continued disregard for good research evidence (much produced by
the College’s own members) in favour of ideology and political correctness
could do just that.
Prof Tom Burns
Prof Swaran Singh
Competing interests:
None declared
Competing interests: No competing interests
Singh and Burns present an interesting argument about racism in
mental health. However we fear that their paper risks setting psychiatry
back twenty years, by denying the impact of racism within psychiatric
settings.
Their paper moves rapidly from a rebuttal of Lee Jaspers comment that
mental health services are institutionally racist to an attempt to deny
that racism has any influence at all on mental health or mental health
sources.
Their argument of the universality of the high rates of psychotic
disorder in all immigrants globally, including Britons, Germans and
Italians migrating to Australia fails to note that the rates in the UK are
higher for 2nd generation African-Caribbeans who are not immigrants.
Furthermore, the study they cite states that the striking finding from the
meta-analysis was the particularly increased risk of psychosis in black
versus white migrant populations and goes on to talk about the likely
importance of psychosocial adversity i.e. racism. (Cantor-Graae E, Selten
JP. Schizophrenia and migration: a meta-analysis and review. Am J
Psychiatry 2005:162:12-24)
Most studies to date have focussed on biological differences and not
social factors. Research of social or service-related factors, have
usually been small-scale, often limited to secondary analyses and with a
susceptibility to multiple confounders.
Trying to unpick racism with an epidemiological study will always be
difficult, but the limited evidence available suggests that racism does
have an influence and is worthy of investigation.
They make several points about compulsory detention and the finding
that African-Caribbean patients present later and often via the police
stating that “A legitimate question is whether some groups of patients are
more likely to refuse help from psychiatric services. And if so, why?”
This seems to us to be a very sensible question to ask, but it seems naïve
to assume that the reason is solely because of lack of family support. An
alternative explanation could be that services are perceived as culturally
inappropriate thus presenting barriers to their accessibility.
Sing and Burns suggest that talking about racism is liable to make
things worse, “becoming a self-fulfilling prophecy”. The policy of the
Royal College of Psychiatrists is to consider whether the accusations are
correct and if they are then to do something about them rather than to
deny their existence.
The authors agree that “racism is indeed prevalent in society” and
that “there are real ethnic inequalities in healthcare that merit
exploration”. They are not alone in advocating the need for good, sound
research with appropriate classification of ethnicity.
However, if our goal as mental health professionals is to provide
appropriate services to all our patients, we have to consider all the
factors which potentially impact on their mental health and on service
delivery. And this includes institutional racism*.
*as defined by Sir William MacPherson in the Report of the Stephen
Lawrence Inquiry 1993
Professor Sheila Hollins
President, The Royal College of Psychiatrists
Dr Parimala Moodley
Chair, Special Committee on Ethnic Issues
The Royal College of Psychiatrists
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor
Dr Pandarakalam is right in speculating that the excess of
schizophrenia could be due to misdiagnoses of atypical psychoses in Afro-
Caribbean population. However, this hypothesis has been specifically
tested in recent studies. There is no evidence of an ethnic minority
excess in atypical psychoses in the UK (1). The rates of mania are also
high among Afro-Caribbeans, suggesting that whatever is driving the excess
of schizophrenia in this group also increases risk for mania (2). Dr
Ramsewak’s audit is a timely reminder that even well-known assertions such
as excess use of medication on some ethnic minorities have not always been
based on sound evidence. We also agree with other commentators that
cultural factors must be taken into account in the consultation process,
that user and carer provider feedback is essential for improving services
and that any such improvement requires action at many fronts.
Professor Bhopal asserts that racism is alive and well; from his own
examples, in Europe and elsewhere. We do not deny the existence of racism.
Our point is that endowing racism with the power to explain all ethnic
differences in rates of psychosis and adverse pathways to care is neither
convincing nor evidence-based; there is compelling evidence that there are
other factors involved. Emotive and inflammatory language simply distracts
from the exploration of alternative and more credible explanations.
It is hardly surprising that many individuals detained against their
will are unhappy about it. Despite this, a recent review suggests that
asked some months after the event between 33% and 81% of patients regard
their compulsory admission as justified and/or the treatment as
beneficial. Equally unsurprising patients with more marked clinical
improvement tend to have more positive retrospective judgements (3).
We do not “underestimate the issue of racism”. But conflating the
Nazi Holocaust or Rwanda massacre with mental health care does a gross
disservice to ethnic minority patients and to their healthcare providers.
It also degrades the memory of the victims of racial and ethnic violence.
We hope that our BMJ article will usher in a period of more tolerant,
inclusive and reflective discussion of this important area.
Professor Swaran P Singh
Professor Tom Burns
1. Singh SP, Burns T, Amin S et al Acute and transient psychotic
disorders: precursors, epidemiology, course and outcome Br. J. Psychiatry,
185: 452 - 459.
2. Fearon P, Kirkbride J, Morgan C et al Incidence of schizophrenia and
other psychoses in ethnic minority groups: results from the MRC AESOP
Study. Psychol Med. 2006 Aug 29;:1-10 [Epub ahead of print]
3. Katsakou C & Priebe S: Outcome of involuntary hospital admission -
a review. Acta Psychiatrica Scandinavica 2006; 114:232-241
Competing interests:
None declared
Competing interests: No competing interests
Race and mental health: there is more to race than racism
Editor,
it strikes me, after finally getting around to reading the Singh and Burns article and the various responses, that similar generalist discussions do not take place over diabetes and hypertension. It disappoints me that they still do over psychiatric illness, although the intellectual tools to avoid such fruitless discussion have been with us for about 100 years. Karl Jaspers (not a Nazi) made the important point that plausible accounts of how psychiatric illness arises are not necessarily true [1,2]. We have to rely on the logic of empirical research to derive our (temporary) certainties. To claim that the discussion of empirical data "sets psychiatry back 20 years" is perverse and makes a mockery of the Royal College of Psychiatrists motto "Let wisdom guide".
[1] Ebmeier KP. Explaining and understanding in psychopathology. Br J Psychiatry. 1987 Dec; 151: 800-4.
[2] Jaspers K. (1963) General Psychopathology. Manchester University Press.
Competing interests:
None declared
Competing interests: No competing interests