Black and mad

"'Schizophrenia' is emblematic of the oppression and mistreatment of black people by psychiatry." Phil Thomas.

Writing in the internationally renowned blog Mad in America, Phil Thomas examines why any investigation into 'schizophrenia' must consider black perspectives very carefully.

When David Bennett died, pinned face down beneath the bodies of four nurses in a secure psychiatric unit, he was just thirty eight years old and had a diagnosis of schizophrenia. It took him twenty eight minutes to die, an augenblick that marked not only the end of his life, but also an eighteen year period in which he had been shuttled between hospitals, jails, secure units and the community. Out of hospital no one apart from his family really seemed to be concerned about him, or for him, or what he was doing with his life. In hospital he was seen as a difficult patient, potentially violent, a nuisance.

The night he died he had tried to phone his sister to discuss a forthcoming home visit, but the phone was in use by another patient. When he returned a few minutes later it was still in use, so he hit the man; they fought and were separated. Then they fought again, at which point David was moved to another ward. When he discovered that he was the one who had been moved, and that the other patient was staying put, he punched a female nurse in the jaw. That was the incident that led to his restraint – and to his death.

David was a Rastafarian. He moved to England from Jamaica  when he was eight years old in 1968. Throughout his contact with mental health services he experienced overt and covert racism of various forms. This is not to excuse his actions; understanding someone’s actions is not to condone them. But it does cast his life and death in a different light. In 1993 he sent a letter to the head of nursing services in the clinic in which he was detained. He wrote:

"As you know, there are over half a dozen black boys in this clinic. I don’t know if you have realised that there are no Africans on your staff at the moment. We feel there should be at least two black persons in the medical or social work staff. For the obvious reasons of security and contentment for all concerned please do your best to remedy this appalling situation." (NSC NHS, 2003:9)

During the fight on the evening of his death, the other patient called him a ‘black bastard’ and shouted at him: "You niggers are all the same" (ibid:16). One of his consultants said that David was on higher levels of medication than any other patient she had ever seen. She thought that this was because of his ‘aggressive and impulsive’ behaviour. She didn’t believe that it had anything to do with the fact that he was black, only that he "…might have perceived slights more readily" (NSC NHS, 2003:11)

Sadly, David Bennett is not an isolated case. In 1984 Michael Martin died in Broadmoor, the high secure hospital to the west of London. Four years later, Joseph Watts died in the same hospital. In 1991, Orville Blackwood died of heart failure after being forcibly injected with a combination of promazine and fluphenazine decanoate, again in Broadmoor. All three men were black. According to MIND (2003), in evidence submitted to the inquiry into David Bennett’s death, there were twenty seven deaths of patients from Black and Minority Ethnic (BME) communities in psychiatric care between 1980 and 2003 – an average of over one a year. Ten years earlier, the official inquiry into  the death of Orville Blackwood commented on the presence of an ‘organisational racism’ in the hospital  and that "…staff and management do not seem to appreciate how this subtle form of racism operates"  (SHSA,1993).

The death of any patient in psychiatric care is a tragedy; the deaths of so many young black men is a scandal.

Of course, psychiatry is not practiced in a vacuum as many psychiatrists believe. Its practitioners reflect the values and beliefs shared by the majority, its institutions likewise. We may be appalled by these deaths, but we are foolish if we are surprised by them. British society remains racist in many areas. The scales fell from the eyes of the more liberal sections of the British public after the racist murder of the black teenager Stephen Lawrence in 1993, and the subsequent failure of the Metropolitan Police to investigate the crime properly, and the failure of the Crown Prosecution Service to bring about a successful prosecutions of the five suspects, all white. The public inquiry into these events concluded that institutional racism was at the heart of this failure, the same institutional racism described by Stokely Carmichael at the Dialectics of Liberation Congress organised by R. D. Laing, David Cooper and others in London back in 1967 (Carmichael, 1968). Shortly after the publication of the Macpherson Inquiry into Stephen Lawrence’s murder, Kwame McKenzie wrote about the significance of its findings for the NHS:

"Health disparities are brought about and perpetuated not only by culture, class and socio-political forces external to medicine, but also by the ideology of the medical profession. This ideology leads to ineffective or no action in the face of disparities and to a lack of concerted effort to teach or discuss racism in medicine in undergraduate and postgraduate curriculums." (McKenzie, 1999: 616 – 615)

In mental health, the disparities referred to by Kwame McKenzie have blighted the lives of Black people living in England for decades, a blight symbolised for many by David Bennett’s death. African and African-Caribbean people in England are much more likely to be diagnosed as suffering from schizophrenia (e.g., Cochrane, 1977; Carpenter & Brockington, 1980; Dean et al, 1981; Harrison et al, 1988; van Os et al, 1996). Rates of admission to psychiatric hospitals in England for African-Caribbean men are three to thirteen times higher than White men; African and African-Caribbean people are much more likely than white people to be detained under the MHA (Bebbington et al; 1991; Moodley & Perkins, 1991; King et al, 1994;  van Os et al, 1996;  Davies et al, 1996). African-Caribbean men are over-represented in forensic units, on remand and in prison (Coid et al, 2000; Jones & Berry,1986); admission rates to forensic units for Black women are three times those of white women (Maden et al, 1992). Black people (13%) are less likely to be granted bail than White people (37%) on basis of psychiatric reports (NACRO, 1990). And the evidence of the inequalities experienced by Black people goes on, and on, and on. How much more evidence do we need before something is done?

The awfulness of this situation deepens when we remember that this has been going on since the earliest days of psychiatry. Suman Fernando (1991) draws attention to the racist nature of the diagnostic categories used by psychiatrists in the USA at the time of slavery. For example, drapetomania used by an American proto-psychiatrist Cartwright (1851), diagnosed the ‘madness’ of slaves who ran away from their white masters. Savages must be mad if they refused to remain subservient to the White man’s beneficent and civilising influence. More recently Metzl’s (2009) compelling academic research shows how, during the struggle for civil rights, African American protestors were diagnosed with schizophrenia for political reasons.

If there is a single word that is emblematic of the oppression and mistreatment of black people by psychiatry, that word is schizophrenia. Surely it is time to abandon this discredited label, and follow the lead set by ISPS (formerly the International Society for the Psychological Treatment of the Schizophrenias and other Psychoses) whose members voted in early 2012 to drop the word ‘schizophrenia’ from its title.

However, that’s not the view of the Schizophrenia Commission (see my blog, 'English Madness: Vox Populi').  Its organisers assume that ‘schizophrenia' is a valid diagnosis, and an unproblematic concept. They say they are interested in all perspectives, but twelve of the fourteen commissioners are either academics, some of whom have made their careers by carrying out research into schizophrenia in Black communities, or senior figures in health and social care. Little wonder that many Black survivor groups expressed a great deal of concern when they found that the commission was being set up without any real attempt to engage with Black perspectives. How is it possible to set up such an investigation without involving those whose lives are most adversely affected by this baleful label?

In response to this disquiet, a group of activists (Jayasree Kalathil, Jan Wallcraft, Suman Fernando, Philip Thomas) have set up the Inquiry into the 'Schizophrenia' Label (ISL). We have tried hard not to take anything for granted about ‘schizophrenia’, the great range of experiences and meanings that are bundled together under this ragbag, the infinite variety of (usually) painful experiences that cower beneath its shadow. We believe that the Inquiry (which is unfunded, and which does not involve anyone who receives funding to undertake research into schizophrenia) can access the views of people for whom 'schizophrenia' is not a universal given. We encourage you to have your say about ‘schizophrenia’ and welcome your experiences of it at the ISL website. Please visit the website  www.schizophreniainquiry.org for more information and to submit evidence to the Inquiry.

References

Bebbington, P., Feeney, S., Flannigan, C. et al (1991) Inner London collaborative audit of admissions in two health districts. II: Ethnicity and the use of the Mental Health Act. British Journal of Psychiatry, 165, 743-749.

Bhui, K. & Bhugra, D. (2002) Mental Illness in Black and Asian ethnic minorities: Pathways to care and outcome. Advances in Psychiatric Treatment. 8, 26-33.

Carmichael, S. (1968) Black Power. In (ed . D. Cooper) The Dialectics of Liberation. Harmondsworth, Penguin. (pp.150 – 174)

Cartwright, S. (1851) Report on the Diseases and Physical Peculiarities of the Negro Race. New Orleans Medical and Surgical Journal, May , 1851 (pp. 691-715); reprinted in (eds) A. Caplan, H. Engelhardt and J. McCartney, Concepts of Health and Disease. Reading, Mass; Addison Wesley, 1981.

Carpenter, L. & Brockington, I. (1980) A study of mental illness in Asians, West Indians, and Africans in Manchester, British Journal of Psychiatry, 137, 201-205

Cochrane, R (1977) Mental illness in immigrants to England & Wales. Social Psychiatry, 12, 25-35.

Coid, J., Kahtan, N., Gault, S. et al (2000) Ethnic differences in admissions to secure forensic psychiatry services. British Journal of Psychiatry, 177, 241-247.

Davies, S., Thornicroft, G., Lease, M. et al (1996) Ethnic differences in the risk of compulsory psychiatric admission among representative cases of psychosis in London. British Medical Journal, 312, 533-537

Dean, G., Walsh, D., Downing, H. & Shelley, E. (1981) First admissions of native-born and immigrants to psychiatric hospitals in South-East England. British Journal of Psychiatry, 139, 506-512.

Fernando, S. (1991) Mental Health, Race and Culture. Macmillan / Mind, Basingstoke.

Harrison, G., Owens, D., Holton, A., Neilson, D. & Boot, D. (1988) A prospective study of severe mental disorder in Afro-Caribbean patients. Psychological Medicine, 18, 643-657.

Jones, G. & Berry, M. (1986) Regional secure units: the emerging picture. In Current Issues in Clinical Psychology. IV (ed. G. Edwards) London, Plenum Press.

King, M., Coker, E., Leavey, G. et al (1994) Incidence of psychotic illness in London: comparison of ethnic groups. British Medical Journal, 309, 1115-1119.

Maden, A., Swinton, M. & Gunn, J. (1992) The ethnic origins of women serving a prison sentence. British Journal of Criminology, 32, 218-221.

McKenzie, K. (1999) Something borrowed from the blues? We can use the Lawrence inquiry findings to help eradicate racial discrimination in the NHS. British Medical Journal, 318, 616–617.

Metzl, J. (2009) The Protest Psychosis: How Schizophrenia Became a Black Disease. Beacon Press, Boston.

MIND (2003) Evidence to The Independent Panel of Inquiry into the events leading to the death of David Bennett

Moodley, P. & Perkins, R. (1991) Routes to psychiatric inpatient care in an inner London Borough. Social Psychiatry and Psychiatric Epidemiology, 26, 47-51.

National Association for the Care and Resettlement of Offenders (1989) Race and Criminal Justice. London, NACRO.

NSC NHS Strategic Health Authority (2003) Independent Inquiry into the death of David Bennett: An Independent Inquiry set up under HSG (94)27.

SHSA (Special Hospitals Service Authority,1993)  Report of the Committee of Inquiry into the Death in Broadmoor Hospital of Orville Blackwood and a Review of the Deaths of Two Other Afro-Caribbean Patients: ‘Big, Black and Dangerous?‘ (Chairman Professor H. Prins) London: SHSA)

van Os, J., Castle, D.J., Takei, N., Der, G & Murray, R. (1996) Psychotic illness in ethnic minorities: clarification from the 1991 census. Psychological Medicine. 26, 203-208