Chapter 35 - Race, State and Mind

Summary

The period 1960–2010 was a time of marked immigration into the UK from Commonwealth countries, either to fill employment gaps in the UK or to escape hostilities and conflict as many Commonwealth countries secured independence. The political climate of the UK; attitudes to immigration and cultural integration; the evolution of mental health sciences, including British psychiatry and the Royal College; the emerging research evidence; and the controversies around why migrants and minorities appeared to have higher incidence rates of severe mental illness and poorer outcomes were, and are still, all interrelated and contribute to the lives of minorities. In the 1970s, as a community, Black African Caribbean people of the Windrush generation were concerned about their children getting police attention, which occurred in a racist and political climate of oppression. More than sixty years later, the situation has escalated and diversified so that illegal drugs, gangs and violent crime are now stereotyped as ‘Black culture’. Inequalities generated by the education and criminal justice systems, early years care and employment practices are a backdrop against which the mental health systems are positioned to respond to societal harms to the marginalised.

Introduction

This chapter examines the experience of black and minority ethnic communities and the way their mental health needs were understood, recognised, prioritised, discussed and tackled by service providers and commissioners in the UK in the period 1960–2010. The chapter begins with the section ‘Doreen’s Narrative and the Research Evidence’, an experiential narrative account from Doreen Joseph, placed alongside research evidence. This attends to black, Asian and minority ethnic (BAME) children, young people and their families in and against the youth (criminal) justice system. The issues are situated within a broader context of racism derived from a legacy of slavery, colonialism and postcolonialism. BAME people have felt this impact on their education, employment, housing, social circumstances, citizenship and health. To understand how these experiences emerged in a historical, social and political context, we then consider responses from practitioners and policymakers to health inequalities.

Doreen’s Narrative and the Research Evidence

Growing up as a teenager in west London in the UK during the 1970s, I noticed the problem of Black youth falling into the criminal justice system. I saw Black youths being slammed against cars while policemen searched them under the ‘sus’ laws. This was the ‘search under the suspicion’ of criminality. This concerned the Black community because of the distress and shame it brought to parents who were law-abiding citizens and its occurrence in a racist and political climate of oppression.

BAME youth in contact with the criminal justice system is one element of a broader context of culture and politics which determines who gets what resources to live in society and how much. Racism is one of the tools that is used to ensure that ‘the rich get richer, and the little that the poor man has is taken away’ in accord with the so-called Matthew effect of cumulative advantage,¹ named after the parable of the talents or minas in the biblical Gospel of Matthew. The inverse of this is cumulative disadvantage and trauma, which lead to cumulative harms, including for health.² Poverty and dispossession drive some Black youth into criminality to survive. However, historical, economic and political factors are major determinants for this outcome, more so than individual ‘bad’ choices or deviant behaviour. Wider issues of immigration, citizenship, (mis- or under)education, (un)employment, housing and detention/incarceration, fuelled by racism, are pertinent. Ultimately, more structural fairness and equity of opportunity and choice would reduce poverty and disadvantage as well as consequent pathways to criminality. Although I look at the experience of the UK, it also applies worldwide where the legacy of slavery and colonialism has continued through racist policies and legislation.

Marginalisation

Racism has a long history that defines relations between different races, where there is a white hegemony over black people, but it was not always so. Black Africans had the ascendancy from ancient times up until the fifteenth century when Western exploration of Africa took off. Black Africans were powerful and respected; the Egyptians influenced the Greeks and Romans of antiquity. During these black civilised ascendancies, the colour black was equated with good representations and white with evil spirits. ‘Black meant “life”, and white “death”.’³ The situation reversed when Europeans joined in the Arab slave trade of black people in Africa and began to construct representations of themselves as ‘superior’ to the ‘rest’ of the world, separating ‘us’ from ‘them’.

Demonology

In the eighteenth century, the Roman Catholic Church identified the colour black with evil. Black was made an emotional partisan colour, alluding to danger, repulsion and other negative connotations.⁴ Travel stories from the ‘dark continent’ informed conceptions of Europeans in the Enlightenment by contrast with ‘others’ from the Orient.⁵ They equated their ‘whiteness’ with being beautiful, enlightened, cultured, knowledgeable, progressive and modern. The demonology of Black people emerged as a result. Black people were portrayed as lazy, servile, untrustworthy, ‘mad, bad and dangerous’.⁶ The transatlantic slave trade in the fifteenth to nineteenth centuries displaced Africans. Racist views were exacerbated by plantocracy in the British colonies in the Caribbean. The nineteenth-century pseudoscientific racist ‘ranking of races’ chose skin colour, rather than hairiness, to demarcate separation.⁷

Racism is embedded in many economic, political and power relations between the ‘white’ ‘West and the rest’ of the diverse ethnicities of the world.⁸ Western powers colonised many parts of the world, and immigrants from the Caribbean in the 1950s to 1980s; the Kenyan and Ugandan Asians in the 1980s; Ghanaians and Nigerians; those fleeing wars in Sudan, Somalia, the dissolved Czechoslovakia in the 1990s and Afghanistan and Syria today all mean that the world has come to Britain and it has become multiracial, multicultural, multi-ethnic, multifaith: cosmopolitan. White Britons at certain historical moments have been intolerant and tensions have overspilled. Right-wing racism and discrimination are very visible even today but are dressed up as neoliberal policies and practices designed to obscure the ways in which inequalities are generated and power relations sustained.

Criminalised

Immigration policy has been the mechanism by which Britishness and foreignness were defined. Creating a hostile environment to deter immigration was a response to public protests of scarce resources, perceived threats to British culture and perceived relatively liberal immigration policies. This hostile response was started in 2007 by Labour’s home secretary John Reid and continued by the Conservative home secretary Theresa May from 2010 to 2016. This hostile response included criminal justice system actions to criminalise, legally identify and remove those coming to the UK; importantly, many who were unable to produce proof of the right to remain were also denied citizenship. When the UK was seeking workers from Commonwealth countries, the variety of visa options under which people could come and work often denied them and their children the right to remain and to full citizenship, resulting decades later in disputes about citizenship rights.

The Windrush generation arrived in the ‘Mother Country’ as invited members of the Commonwealth but were met with culture shock – there were no gold streets but hostility – ‘no Blacks, no dogs, no Irish’.⁹ Blatant racism and oppressive discrimination meant life was a challenge; and employment was often only available in low-level, low-skilled positions in factories, in the newly formed NHS, in the transport system or in construction to rebuild the infrastructure of post–Second World War Britain.

They ‘sent’ for their children from the Caribbean, while some children were born in Britain. Those who had been educated in the British colonial West Indies education system (to a high standard) now found that they were subjected to racism in British schools. Although some attended grammar schools and achieved O levels and A levels, others found themselves relegated, unjustly, to so-called educationally subnormal (ESN) schools.¹⁰ Efforts were made to correct ‘The Miseducation of the Black Child’ through supplementary Saturday schools.¹¹ Hazel V. Carby’s chapter ‘Schooling in Babylon’ in the edited volume The Empire Strikes Back and Gus John’s book Taking a Stand show how the Black community were ‘taking a stand’ to address this travesty.¹²

The trajectory, however, was already set. Many were demoralised and disaffected. Ignored or undereducated by teachers, left to their own devices – listening to ‘ghetto blaster radios’ at the back of the classroom – some would stray into more deviant behaviour. The Black community and Black teachers tried to ameliorate antagonistic race relations by introducing ‘multiculturalism’ in schools but that too suffered a backlash.¹³

These developments occurred against a backdrop of rebellion and revolution in the 1960s and 1990s, with colonies gaining independence, the civil rights movement, the rise of Black Consciousness, Black Power and the reformed self-image of ‘Black Is Beautiful’. As young people, we began to learn about Black History from courageous white and black historians.¹⁴ Simultaneously, many youth were turning to Rastafarianism,¹⁵ alienated from Christianity, which they associated with oppression and slavery. Hopes were raised for recognition of Black Power and values when apartheid (1948–94) was overthrown in South Africa and Nelson Mandela was released after twenty-seven years’ imprisonment (1990) to later become the president of South Africa (1994–9). However, some felt that Mandela might have been brainwashed because he was no longer militant but followed Christian values of forgiveness, paving the way for reconciliation.

Social control was being exerted by government policies, causing division between races and social classes. This process of racist segregation starts very early on in the education system.¹⁶ Indeed, in 1979 Coard stated that black (and mixed-race) children (and poor, white working-class children) would be minimally educated to maintain the ‘social hierarchy’ and ‘an abundant’ supply ‘of unskilled labour’.¹⁷ A white ‘career’ offender claimed that, instead of places of reform, ‘prisons were colleges for criminals’, where young offenders are taught more criminality from seasoned inmates.¹⁸

Education according to state strategies was (and still is) ‘more for social control of black youth’ and of black people in general.¹⁹ In recent decades (2000–19), black children have been placed in Pupil Referral Units (PRUs), decried by some because schools and local councils received up to four times as much funding for each pupil as they would in mainstream schools, yet there are few teaching resources and the children are left to their own devices. Is history repeating itself? Epidemic proportions of black children are being excluded from schools, especially in inner cities. Parents are desperate, as they have little disposable income and must work so they can’t supervise or teach their children. More determined parents resort to homeschooling, which is a challenge because the schools and councils refuse to release the funds that are rightfully for each pupil, so parents are forced to pay for costly private tuition.

Returning to black–white race relations, with rising unemployment, unions striking and far-right factions taking root, racism resurfaced, culminating in clashes, riots, racial attacks and injustice from the 1960s to the latest riot in 2011. I remember the battles between white and BAME youths as extreme racists went ‘Niggah hunting’ or ‘Paki bashing’. During that time, Asians allied themselves to Black people as having a common enemy and seeking racial equality and justice. The police, however, were often ‘too’ ready to arrest Black youth whom they suspected of vagrancy and, in later years, of possession of illegal substances or weapons. The ‘sus’ law, which began under the ‘suspected persons’ stop-and-search section of the Vagrancy Act 1824, was used increasingly on Black youth during the 1970s and 1980s and was acutely felt in the post-Powell (racist) climate. Modern-day stop-and-search disproportionately targets black people today. Some things just do not change but are dressed up and justified in contemporary discourse and rationales that are clearly discriminatory but politically pushed through. After the riots in 1981 the Criminal Attempts Act repealed the sus law; but this was reversed in 1984 by the Police and Criminal Evidence Act (PACE), in effect reinstating sus. In 2000, section 44 of the Terrorism Act legitimated the racially profiled sus; but, in 2010, it was ruled illegal under the human rights agenda, though it continues under section 60.

Because of riots, Black youth were portrayed in the media as ‘savages, rapists and rampagers’.²⁰ Van Djik avers that sources were only quoted because they fit into the dominant discourse and confirm general attitudes about Black people.²¹ Soon, many Black youths found themselves in youth offender centres or prisons.

Victimised

In addition to sus on the streets, police often raided ‘house’ parties, nightclubs, ‘shebeens’ and homes where they suspected cannabis (or ‘weed’, ‘ganja’) was being used. The emergent Rastafarian community were often targeted, even though their young people were more well behaved than deviant. The ‘crimes’ diversified as more ‘Black on Black’ violence became prominent, and knife and gun crimes have become more prevalent today, with increasing numbers of young people killed year on year – 132 in London in 2019, the bloodiest in a decade. Rather than examine the history and social conditions and legacies of violence and oppression, modern commentators still resort to cultural and racial pathology, proposing that black people need to take care of their addictions, mental illnesses and propensities to join gangs rather than that these are manifestations of clustered disadvantage and geopolitical drivers of multiple problems.²²

Nevertheless, some of the killings were racial, as notably the thirteen Black teenagers who died in a fire at a house party in Newcross, south London, in 1981, which sparked protests.²³ As was the fatal stabbing of eleven-year-old Damilola Taylor in 2000 and of eighteen-year-old Stephen Lawrence in 1993. In the latter case, it took eighteen years for his mother to get justice and hold the police and judiciary up to scrutiny and obtain a new ruling. A change in legislation to partially revoke the rule of not being able to prosecute for the same offence twice (double jeopardy) eventually enabled two of the defendants to be convicted and imprisoned. In the MacPherson Report in 1999 of the inquiry on the Stephen Lawrence case, there are 382 mentions of the word ‘racist’. In his inquiry report, MacPherson said that ‘institutional racism’ had hampered the investigations. Since then, this term has then been applied as a lens through which to consider inequalities in other public services. More recently, ‘unconscious racism or bias’ has been proffered to explain (excuse) racial harassment cases.²⁴ It is regrettable that racism in health care remains a concern and some still dispute its relevance.²⁵

Such processes are unacceptable to Black communities when members are attacked, maimed or killed by police – police who are supposed to protect citizens. In 1985, three Black women, Cynthia Jarrett, Cherry Groce and Joy Gardner, were maimed or shot by police during raids on their homes who were allegedly searching for suspected criminals. Riots broke out in Tottenham’s Broadwater Farm Estate and in Brixton, south London.²⁶

The world was shocked in August 2011, when riots erupted in London and other UK cities, as well as arson attacks in Croydon, south London, after minicab passenger Mark Duggan was shot dead, ‘execution-style’, by police marksman. The police said it was drug-related; but whether it was or not surely arrest and then a fair trial is the usual route, not ‘shoot first and ask questions later’?²⁷

Invisibilised

‘Disappear or become invisible’ seems to be the underlying desire of racists towards Black people. Queen Elizabeth I expressed this sentiment. Called the greatest English monarch, her wealth and success came from slavery and sea battles in the West Indies. Yet, in 1596 and 1601, she issued proclamations to expel ‘those kind of people’, namely ‘blackamoors’ and ‘nears’ from ‘her realm’.²⁸ Her attempts at immigration control failed and this has been a contentious issue, since I contend that Black people are considered too ‘visible’ in British society. Gary Craig also argues that the lack of focus on race has led to the ‘invisibilising’ of race within current policy.²⁹

This I realised in 1998 when a Brazilian told me that Brazil had paintings where Black people were painted without defining features. They would have faces but no eyes, nose or mouth – dehumanising or ‘invisibilising’ them. The Roman Catholic Church in the Middle Ages behaved ‘schizophrenically’ in their apparent ‘memory loss of the very real and influential presence of Moors (Moslem Africans), who invaded, conquered and ruled the Iberian peninsula, especially Spain, for 700 years from AD 711. The church gleaned the superior knowledge and science from the Moors who had established or influenced universities in Europe and in Oxford, England, but hid this from the masses because they feared the loss of church power and influence. Shakespeare’s play Othello also evidences Black influence.³⁰

The Windrush generation were not the first Black people in Britain, but decades of race relations have not brought them or their descendants closer to a sense of being welcome or ‘belonging’ here. However, their British-born children and grandchildren expect to be treated the same as other British people, to have an equal share in the society’s resources and equal life chances.

State initiatives to forcibly assimilate immigrants have had little success and are resisted. Naturalisation tests (2005) and citizenship tests (2007) were introduced, and immigrants were put under extreme duress and financial burden to ‘prove’ their ‘worthiness’ to be accepted as British citizens. These policies would require that BAME people ‘forsake all that makes them out as culturally distinct, before real Britishness can be guaranteed’.³¹ Furthermore, fear aroused from 9/11 in the United States and 7/7 in London exacerbated hostilities along religious, cultural and racial lines.

Pathologised

Another concern for Black youth is that they are pathologised, with some sent to mental institutions. Diagnosed by psychiatrists (with ‘unconscious biases’ or susceptible to ‘institutional racism’) or ‘misdiagnosed’,³² they are sectioned, (over)medicated or incarcerated, disproportionately, in forensic and medium-secure mental institutions for lengthy periods. There is no natural explanation grounded in genetics or race, as such notions are scientific nonsense. The histories, legacies and conditions of life are responsible and yet ignored. Even following the experience of mental illness, black people receive coercive care, more medication and biological treatments rather than psychotherapy or sufficient social intervention.

Notable cases of Black men who have died in custody include David ‘Rocky’ Bennett, Sean Rigg and many more. Rigg’s family published a list of 3,180 people who had died in police custody, prison, mental hospitals or immigration detention camps in the UK between 1969 and 2011.³³ Bennett’s sister’s campaign inspired the Delivering Race Equality (DRE) initiative and the Race Equality Cultural Capability (RECC) training (2005–10) to raise race and cultural awareness and minimise racist practices.

Black children’s homes are regarded as ‘dysfunctional’ and ‘not good enough’ by social services, who remove children and put them into foster care or up for adoption, usually to white parents. The stereotypical Black family is perceived to be matrifocal or matriarchal, denoting the ‘absence’ of fathers because of the preponderance of ‘baby mothers’. However, this does not acknowledge the part slave owners played in separating families and siring illegitimate mixed-race children themselves, which have left single parenting as its legacy into modern times.³⁴ Traditional African families say that ‘it takes a village to raise a child’. However, slavery destabilised this family structure; and other deliberate ways to degrade and disable Black people, and keep them ignorant of their history, their moral and scientific principles, through sexually charged and violent music, are orchestrated by controlling factions (hip-hop’s Professor Griff, 2010).³⁵

Identity, Aspirations and Resolve

Given all these factors, it is not surprising that Black youth may be confused on issues of belonging, identity, self-image, self-esteem and worth. With a barrage of negativity through media, society and community, they may have internalised this,³⁶ which may explain how ‘self-hatred’ and ‘Black on Black’ violence have taken hold. Whether they want protection, ‘respect’ from ‘olders’, or father figures, to be feared or want to make ‘quick money’, more Black youth have joined gangs.

They also identify with ‘celebrity’ music artists (hip-hop rappers, grime or drill) who talk about experiences they can relate to. Rastafarian ‘Black conscious’ reggae songs promoted Black pride and positive self-image. Black youth can reject the negative impositions on their identity and reach out for a universal humanity that fosters justice, equality and equity.³⁷

Research Evidence and New Directions

The narratives of oppression are supported by much evidence on ethnic inequalities of incidence and experience of mental health systems in which some black minority groups and migrants experience more coercive care.³⁸ This includes more adverse pathways to care through criminal justice systems, police involvement and use of the Mental Health Act. Part of the challenge is a reductionist approach that sees mental illness as a product of individual failings or exposures to risk factors rather than a dynamic balance of resilience and risk factors over the life course and that in specific social contexts is too simplistic. That is, assets have a positive influence cumulatively and likewise risk factors a negative influence. Indeed generations of traumatic experiences (genocide, slavery, religious, ethnic or racial persecution) continue to have evident impacts on future generations. These are transmitted through narratives of identity and how these are often shaped by histories of persecution. A further problem is the web of causation, including social divisions and status; stratification by poverty, employment and housing; and safety and trust in neighbourhoods. These rarely feature as structural factors that offer potential explanations for why some groups continue to suffer greater adversity, thus leading to poor mental health (see also Chapters 3 and 5).

A historical perspective on life in Britain during the period 1960–2010 therefore becomes important. Historical documents can reveal prevailing attitudes to mental health care and mental illness and attitudes towards migrants and minorities not only in official policy and practice but also in popular culture. Boxes 35.1 and 35.2 present, respectively, British health policies during this time, and as a way of tapping popular culture, situation comedies during the same approximate period. The documents and shows listed in Boxes 35.1 and 35.2 could be examined, interrogated and explored for popular cultural stereotypes and for information on how ethnicity, race and cultural diversity were viewed. The situation comedies openly show racist language, ostensibly to call out bigots but reinforcing common attitudes towards minorities and not considering the power imbalances (e.g. Spike Milligan’s Paki-Paddy from Curry and Chips). More recent decades have seen black actors and comedians reverse this situation by taking leading roles and directing and writing the material for comedies in an attempt to share both the ironies and the realities of their lives (e.g. The Fosters, Desmond’s, The Kumars at No. 42 and Goodness Gracious Me).

Box 35.1 Relevant Health Policies, 1959–2020⁴⁰

1959

Mental Health Act

1975

Better Services for the Mental Ill White Paper

1976

Joint Care Planning, Health and Local Authorities

1981

Care in Action: A Handbook of Policies and Priorities

1982

Korner Report: collecting NHS data

1983

Mental Health Act

1986

Making a Reality of Community Care

1988

Community Care: An agenda for Action. Sir Roy Griffiths’s report into the care of Sharon Campbell

1990

NHS & Community Care Act

1992

Mental Health as a Key Area in Health of the Nation/Joint Home Office and Department of Health review on care of mentally disordered offenders (MDO)

1993

Mental Illness: Key Area Handbook/Mental Health and Britain’s Black Communities

1994

Richie Report on care of Christopher Clunis/Guidance on Supervision Registers, aftercare of MDO and care in the community/Mental Health Taskforce in London and regions; Black Mental Health: A dialogue for change; NHS letter mandating collection of ethnic group data for inpatients; establishment of NHS ethnic health unit

1995

Mental Health Patients in the Community Act/Mental Health: Information booklet on ethnic minorities service users and carers

1997

The New NHS Modern, Dependable

1999

National Service Framework

1999

Stephen Lawrence inquiry

2000

Race Relations Amendment Act

2002

Commission for Race Equality: guidance for organisations

1998–2003

Inside Outside: Improving Mental Health Services to Black and Minority Ethnic Communities in England

2007

Ethnicity and Health. Parliamentary Office of Science and Technology

2005–2010

Delivering Race Equality

2007

Government decides to not use the term ‘institutional racism’ or ‘racism’

2010

Equality Act. Silence and Invisibility as DH and many government bodies removed the term ‘institutional racism’ from official vocabularies and policy

2018

Synergi Collaborative Centre established

2019

Independent review of the Mental Health Act

2019/20

Covid legislation and crisis

Box 35.2 Popular Television Reflecting Societal Attitudes to Race and Immigration: Using Comedy to Attack the Bigot

1965

Till Death Us Do Part

1968

Carry On Up the Khyber (same year as the ‘Rivers of Blood’ speech)

1969

Curry and Chips (with Spike Milligan’s Paki-Paddy)

1972

Love Thy Neighbour

1974

It Ain’t Half Hot Mum

1974

Rising Damp

1976

The Fosters (first comedy with black characters)

1977

Mind Your Language

1984

The Cosby Show

1989

Desmond’s

1995

Porkpie

1998

Goodness Gracious Me

2001

The Kumars at No 42

Certainly, in the 1960s, we have the incredible movement of deinstitutionalisation, which led to the closure of the asylums and the call for community care, greater social care and support in ordinary places, as well as a recognition of the importance of the environment and social space in both causation of mental illness and recovery. It is ironic that, at the end of the National Service Framework (NSF) in 1999, specialised services to support community care have been stripped back, resulting, ultimately, in crisis-only services with little space for rehabilitation and adequate place-based social care (see also Chapters 23 and 26 ). Health inequalities in general were identified by the Black Report and the review by Michael Marmot; and ethnic inequalities were profiled more recently by the Synergi Collaborative Centre.³⁹ These inequalities persist and have not seen a coordinated set of actions by successive governments.

There is no sustained and consistent action on systems change to impact care practices. At the same time, during the period of interest Powell’s ‘Rivers of Blood’ speech stoked hostility towards migrants and minorities, and the ramifications are still felt today, with contentions around whether racism was and is a helpful term, specifically institutional racism. Furthermore, the legacy of the Windrush generation has not been overlooked, when, even recently, a hostile environment for immigrants under the May government appears to have been repeated and expressed past colonial attitudes. Historical moments lead to products that show an underlying default of hostility towards perceived aliens, often the underclasses and the poorer and most vulnerable in society. The visibility of historical moments, monuments even to British identity, fluctuates and some consider these events as irrelevant to modern life in Britain, contrary to the lived experience of being black in Britain.

Policy and Research Discourse

The language of policy and research lacks ambition or motivation, being grounded in modest recognition of inequalities in society, given the challenge these pose politically and the necessary additional spend required. Most research provides evidence for the majority which may then be applied to minorities, or those with clustered disadvantage. Ambivalence and divergent political, policy, research and clinical perspectives tend to favour the advantaged, the least unwell, the most well off who are already well placed and make best use of the interventions; thus these actions widen inequalities.⁴¹

Psychiatry and Culture

Psychiatric practice and research made incredible advances in the 1960s-1990s, but since then there seems to be little innovation in terms of pharmacological or social or psychological interventions (see Chapters 2, 17). Work continues to repurpose medication, develop better and more cost-effective psychological therapies, and consider the social drivers of poor mental health. The role of race and culture has a more chequered history with psychiatry and psychology being implicated in early research and practice as being racist, culture blind, and reinforcing stereotypes. Indeed, the very power structures of society are replicated in institutions, and psychiatrists are increasingly seen as public servants who act for the government and the socially constructed public good.

Wittkower established a newsletter in 1956 called Transcultural Research in Mental Health Problems creating a new field of Transcultural Psychiatry, from McGill University Canada, since when Cultural Psychiatry (as it is more commonly called these days) has been established in several countries as a distinct approach. In the UK, the Transcultural Special Interest Group of the Royal College of Psychiatrists is the nearest to a membership society that has stood the test of time; others have come and gone, including NGOs, and charity partners, ethnicity and health units. The World Psychiatric Association has a Transcultural Section and the World Association of Cultural Psychiatry was formed in 2008. Initially Transcultural Psychiatry, as it was originally termed, was dominated by anthropological research methods and, more recently, additional qualitative and quantitative approaches are applied for the same purpose, to better understand cultural influences in the expression and presentation of mental disorders, and across distinct cultural groups, ethnic groups, and races. The latter as a focus of concern is especially common in North American discourse but has had an uneasy existence in the UK, where notions of racism and race equality remain contentious, provoking ambivalence amongst government, policy makers, commissioning bodies and research leaders.

British psychiatry did not reflect on its own contributions to racist practices and poorer outcomes for some until Julian Leff, Roland Littlewood and Maurice Lipsedge debated and contested psychiatric cultures, followed by Suman Fernando, Dinesh Bhugra, Kwame McKenzie, as well as active members of the Transcultural Special Interest Group of RCPsych (Parimala Moodley and Deenesh Khoosal). With these efforts, attention was more directly drawn to the injustice of mental health care being more coercive and less therapeutic for black and minority ethnic groups. Even this sentence, despite decades of evidence, is still disputed by some commentators whose location of problems is not in race, ethnicity or culture, but in individual risk behaviours, social status and deprivation, and psychosocial adversity including urban environments. All of these are relevant, yet if understood as individual cognitive or behavioural risk factors, rather than products of historical and social contexts, these do not explain the patterns of disparities in the incidence, experiences and outcomes from interactions with health systems. Rather more complex and intersectional and interacting causal and preventive models are required.

Conclusion

Many young black people are ambitious, want higher education, to have professional careers, or own businesses, and are prepared to work hard to achieve their goals. But like some of their parents, they face frustrating racist ‘glass ceilings’, which prevent access or promotion. Yet, encouraged by the resolve of their forerunners, they determinedly fight for their rights, and pursue their dreams. The alternative is demoralisation, depression or worse. The unequal impacts of assessment and treatment in care services compounds, and may even escalate, the detrimental impacts of pre-existing levels of inequality and historical legacies.⁴² Historical injustices are regrettably silenced in contemporary debate, just as crises are full of promises soon forgotten when the political and public gaze shifts.⁴³

Key Summary Points

• The period 1960–2010 was a time of marked immigration into the UK from Commonwealth countries, either to fill employment gaps in the UK or to escape hostilities and conflict as many Commonwealth countries secured independence.

• The political climate of the UK; attitudes to immigration and cultural integration; the evolution of mental health sciences, including British Psychiatry and the Royal College; the emerging research evidence; and the controversies around why migrants and minorities appeared to have higher incidence rates of severe mental illness and poorer outcomes were, and are still, all inter-related to contribute to the lives of minorities.

• In the 1970s, as a community, Black African Caribbean people of the Windrush generation were concerned about their children getting police attention; which occurred in a racist and political climate of oppression. Over sixty years later the situation has escalated and diversified, so that illegal drugs, gangs, and violent crime is now stereotyped as ‘Black culture’.

• Inequalities generated by the education and criminal justice systems, early years care and employment practices are a backdrop against which the mental health systems are positioned to respond to societal harms to the marginalised.

• The powers held in psychiatric systems are often co-opted to reflect the interests, and institutional practices and attitudes, of the state. This is most evident in detentions under the powers of the mental health act and in the forensic and criminal justice systems.