Multiculturalism: bad for your mental health?

For all its claims to be a multicultural society, a form of apartheid is said to be looming in Britain. According to Lord Patel, chairman of the Mental Health Act Commission, within the British mental health system there is one form of care and treatment for whites and another, more coercive and less therapeutic, for blacks (1). But the truth may be far more complex.

Lord Patel was responding to a census report that found that black people were over-represented within psychiatric care. The Healthcare Commission survey, titled ‘Count Me In’, looked at the ethnic background of the 32,023 psychiatric in-patients in England and Wales as of 31 March 2006. The census found that black people were three to four times more likely to be hospitalised than their white counterparts, accounting for 21 per cent of in-patients, even though only making up seven per cent of the general population. (If the ethnic category of ‘black other’, is isolated, the differential rises to 18-to-one (2).)

Given such statistics, it is not surprising that the psychiatric services once again stand accused of institutional racism. The term ‘institutional racism’ with regard to the mental health system came to prominence with the report of the inquiry into the death of David ‘Rocky’ Bennett (pictured above). Bennett, a black patient, died while being physically restrained by nurses at a Norfolk psychiatric clinic. The subsequent inquiry report concluded that racist assumptions and practices had contributed to his death, and stated that institutional racism was ‘a festering abscess, a blot on the good name of the NHS’ (3).

In response to the above, the government has pledged to ‘eradicate discrimination’ in NHS mental health provision. Louis Appleby, the national director for mental health, stated that work was under way to win the trust and confidence of black minority ethnic communities. For him, this was necessary to ‘better understand the wider social factors that result in some communities experiencing a higher rate of mental illness’ (4).

Kwame McKenzie, professor of mental health and society at the University of Central Lancashire, argues that being black in Britain is detrimental to your mental health, and that once your mental state has deteriorated to an acute level you will receive more coercive and discriminatory treatment than your white counterparts (5). Accusations of institutional racism would appear to be well founded. However, a closer look at the issue shows the reality to be more complex than is often reported, and also highlights the danger of pathologising whole communities under the guise of therapeutic aid.

It would be foolish to ignore the role of psychiatry in upholding dominant social mores. Like many professions it has a chequered history when it comes to issues of race, perhaps the most infamous example being the creation of a ‘disease’ called ‘drapetomania’ – a condition said to affect black people who tried to escape slavery. And the recent census merely confirms many similar findings into the over-representation of black people in the mental health system (6).

Nevertheless, it is naïve, simplistic and problematic to blame institutional racism for such a situation. For example, the 21 per cent ‘non-white’ group includes a variety of ethnic groups, including Indian, Pakistani, Bangladeshi, White Irish and ‘Other White’. And whilst it is the case that Afro-Caribbeans are over-represented, other groups such as the Indian and Chinese communities are under-represented. Such discrepancies indicate that there is more to this than ‘race’.

Whilst the reasons for the differentials are complex, it is possible to highlight some relevant factors, including the marginalisation of social class; the fragmentation inherent within multiculturalism; and the rise of the therapeutic professional as the cure for society’s problems.

For example, the fact that most sufferers are unemployed would indicate that social class is a factor in the onset of severe mental distress. Yet while the ‘Count Me In’ census recorded such factors as ethnicity, age and even sexual orientation, social class was conspicuous by its absence. This is revealing in that it illustrates the way our understanding of social problems today tends to be viewed in ethnic or pathological terms rather than the class conflict of yesteryear.

In the process, there is a real danger that whole communities, especially black ones, are being portrayed as victims without agency, awaiting the arrival of mental health professionals to cure them of their ills. Kwame McKenzie notes that ‘psychotic illnesses are associated with poverty, poor education, racism, living in a city… family break up, and cannabis use’. If this is the case, and the associations are extremely complex, then the answer would appear to lie in the realm of the social, rather than the preventative therapy for children and adolescents advocated by McKenzie (7). Improving communities’ access to jobs, education and welfare might be a better bet than treating them as ill and in need of special attention and care.

The other main strategy, and one recommended by the inquiry report into the death of Rocky Bennett, is to improve the ‘cultural awareness’ of mental health staff. But this is to confuse the more minor failings in his care with the more tragic. As Errol Francis of the Sainsbury Centre for Mental Health, who gave evidence to the Bennett Inquiry, points out: ‘How much cultural awareness training does a nurse require before they realise that too much force will kill?’ (8)

The experience of racism, poor housing and employment opportunities, and the pathologising of that experience, are nothing new for black people living in Britain. What is new is how such problems are articulated. In the 1980s, riots in Bristol, Manchester, Liverpool and London saw physical expression given to black marginalisation. Partly in response to this, the government accelerated the idea of multiculturalism, with funds and projects being set up on the basis of ethnic identity.

Could there be a link here? As identity became ever more fragmented around ethnicity, the way to secure funding was not by emphasising collective strength but particular vulnerability and hardship. In addition, the emphasis on difference implied that we had little in common with each other, our neighbours becoming threatening strangers rather than supportive allies. It is unlikely that such processes are conducive to a robust mental state.

Of course, when someone’s mental state deteriorates to the point that professional help is necessary, they should receive appropriate and sensitive care. Awareness by staff of their needs is essential, but these will not always fit as neatly within the ethnic identity template that the authorities want to put us in. The categorisation of people as ethnic identities with certain cultural requirements implies a homogenous, timeless culture that can be as inaccurate as it can be patronising. The answer to most of these problems lies within and between communities. Improved social conditions and relationships of trust will improve the mental health of everyone – not just black people – far better than any ‘preventative’ psychiatric intervention.

Ken McLaughlin is a senior lecturer in social work at Manchester Metropolitan University, England.

(1) Mental health ‘apartheid’ warning, BBC News, 31 March 2007

(2) Count Me In, Healthcare Commission

(3) Independent Inquiry into the death of David Bennett

(4) Mental health ‘apartheid’ warning, BBC News, 31 March 2007

(5) Being black in Britain is bad for your health, Guardian, 2 April 2007

(6) For one example see D. Browne (1997) Black People and Sectioning, Little Rock Publishing: London

(7) Being black in Britain is bad for your health, Guardian, 2 April 2007

(8) See Rocky Bennett – killed by institutional racism