Commentary: institutional racism in British psychiatry

The timing of Professor Sashidharan's provocative article (this issue, pp. 244-247) is excellent for a number of public and personal reasons. First, the subject is one of critical importance for the delivery of mental health services and for the training of mental health professionals when recruitment and retention issues are of such paramount importance. Second, the Council of the College, who have struggled with these issues in the past, have recently endorsed a more radical set of recommendations precisely within the field of his concern.

On a more personal note, in 1989 I coedited a small book entitled Racial Discrimination in the Health Service, which included a chapter by Reesal-Hussain (1989), who described the NHS as ‘sick’ and in a critical condition as a result of neglect, discrimination and racism. She made 13 recommendations to assist the ‘patient’ in making a speedy recovery. Other chapters in this book addressed more direct issues of racial discrimination, for example services for the elderly of ethnic minorities and the disadvantage experienced by graduates of Asian medical schools. For myself, racial sensitivity ‘training’ came about through a series of events that included: working in Uganda during the forced expulsion of the Asian community by Idi Amin; witnessing attempts to devalue transcultural psychiatry by excessive preoccupation with issues of race; and in more recent years a greater awareness of the disadvantage many members of our College have when delivering mental health services in a multiracial society and the possibility that institutions, including Medical Royal Colleges, can discriminate covertly.

Pioneer work by Rack and his Bradford colleagues in the early 1970s (Rack, 1982) was characterised not only by his honesty in recognising he was not trained to provide a mental health service for a multicultural, multiracial society, but also by his courage to set about learning new skills and inspiring others to do the same. This work and much, but not all, of his approach has now seeped into more recent Government mental health policy initiatives — most noticeably in the recent National Service Framework for Adults of Working Age in England. The influence of other College Fellows has also been noticeable. Suman Fernando in particular, through his lucid writings, advocacy and political awareness, has influenced my own thinking considerably and no doubt that of many others. Dr Hettiaratchy has also facilitated College concern in this field and her timely work on the General Medical Council and Mental Health Act Commission has been strategic.

In addition, several publications by Gaskell are also noteworthy. There is now no shortage of books for trainee psychiatrists and consultants within this field, referring to the various texts by Bhugra and Bhui (e.g. 2000), as well as to the more classic contributions from Littlewood and Lipsedge (1982). I wonder, however, when Professor Sashidharan will put into the public domain more of his own rich clinical experience and explain the source of his persistent energy for issues of race since his earlier work in India and Edinburgh (where we jointly launched the Edinburgh Transcultural Psychiatry Society) — before his move to the West Midlands. One core function of the College is public education and promoting research; here our track record is more limited and Professor Sashidharan's influence could be facilitatory.

Patel (1999), a clinical psychologist, has described ethical guidelines for research in a multicultural, multiracial society and challenges us to explain why ethnic minorities can be excluded from epidemiological surveys — many times on the spurious grounds of them not speaking English. Surely this will not do in the future and could even contravene the Race Relations Act.

We are all affected by our culture that we partly recognise, unless totally blind to the water in which we swim. We all have racial characteristics. However, what is often forgotten is a history of colonialism and neo-colonialism, which can still condition present-day discriminatory attitudes. Nevertheless, as a colleague pointed out at a recent Transcultural Psychiatry Symposium, perhaps the time has come to leave behind the ‘chip on the shoulder’ for both Black and White, and to get on with the corporate task of delivering a mental health service in a multi-faith, multiracial and multicultural society.

There are indeed occasions when we can glimpse celebration of a multicultural society and appreciate an intellectual and social excitement from the juxtaposition of different cultural slants on mental health provision and the sharing of a common concern for the mentally ill.

When elected President in 1999 I indicated a wish to provide leadership within this field. This I have endeavoured to do — but with what success? I will attempt to answer this question by recalling three College events.

The recent 2-day meeting that reviewed the MRCPsych curriculum from a sociocultural perspective, outlined training programmes in cultural competence and brought together diverse writers, clinicians, academics and political activists in this field was remarkably productive. There was a clear recognition that the issues described in Professor Sashidharan's article were not only of importance for disadvantaged minorities, but also of critical importance for the well-being of psychiatry as a whole, with the need to identify its ‘Western’ cultural roots and, when necessary, modify these for a multicultural setting. Cultural history is the envelope within which biological, social and psychological theories nest.

Over the past 6 months College officers (myself, Parimala Moodley (sub-Dean), Vanessa Cameron (Secretary) and Deborah Hart (Head of External Affairs)) have been meeting leaders of the Black user groups in London in a de facto Black/White Committee. Their voice needed to be heard because they were not active within the patient and carers liaison group and because large sections of the Afro-Caribbean community in London are disenfranchised from mental health services generally, which are regarded as ‘alien’. This may be one reason for the prolonged delay in accessing treatment for psychosis in this community. It may be for these reasons that the North Birmingham work (yet to be fully evaluated) on the benefits of home delivery and crisis intervention is important. It has yet to be shown, however, whether these services are culture/race-specific, or can be generalised to rural as well as urban England, to Glasgow as well as London and to North as well as South Staffordshire. It is probably premature to develop an NHS plan on the assumption that these service models are of general applicability — until a more firm evidence base is to hand.

Council in February endorsed the new recommendations of a working party that I chaired and decided not to review the earlier report Psychiatric Practice and Training in a Multi-Ethnic Society, but instead to provide evidence in support of new major recommendations.

Ten recommendations were made including:

1. • an independent review to ascertain whether or not institutional racism exists

2. • appropriate training to ensure that all psychiatrists are culturally sensitive and culturally competent

3. • ensuring that Members of the College are aware of the possibility of discrimination or abuse when applying mental health legislation to Blacks and other ethnic minority groups

4. • ensuring equal access to services for all Black and other ethnic minority communities

5. • continuing dialogue with all relevant user groups, including Black and other ethnic minority user groups

6. • the establishment of an Ethnic Issues Committee.

It is now up to the College and the new Ethnic Issues Committee to ensure that the spirit and essence of the recommendations are implemented.

The record of the College, from its origins 30 years ago, is notable on many of the issues raised. Professor Rawnsley, the College's fourth President, provided crucial leadership at a time when the issues were even more ‘difficult’ than they are at the present time.

College Council is now committed to working with the Health and Ethnicity Unit, directed by K. Patel, first to identify and then rectify any deficiencies in its structures and procedures.

I personally believe that when these issues have been fully addressed the vitality of the College will be enormously enhanced, recruitment and retention of psychiatrists improve and that, above all, there could be the return of a greater sense of job satisfaction.