Institutional Racism in Psychiatry and Clinical Psychology

Race Matters in Mental Health

Visit the link below to download the full version of this book:

https://medipdf.com/product/institutional-racism-in-psychiatry-and-clinical-psyc
hology-race-matters-in-mental-health/

Click Download Now

To the memory of Darcus Howe, broadcaster and campaigner
for the rights of black people in the UK, who died on Saturday
1 April, 2017, just as I was finishing this book.

I never knew Darcus personally, but admired him for his

straight talking and grass-roots activism. May he rest in peace.
 PREFACE

This book is somewhat personal in that it reflects many of my own expe-

riences and views, both generally about race matters in British society, and
about racism (mixed up with cultural bias) in the field of mental health, in
particular the practice of psychiatry and clinical psychology.
In the 1960s I embarked on psychiatric training, hoping to build my
career as a psychiatrist in the (British) National Health Service (NHS). I
decided not to apply for a training post at the so-called centres of excel-
lence in London—I had heard that most prestigious centres followed an
old-fashioned institutional approach to patients while some mental hospi-
tals (still very much asylums) were sometimes more forward looking. I
opted to work in training posts in mental hospitals in Epsom while
attending lectures and seminars at the Institute of Psychiatry. Once I had
the diploma in psychological medicine awarded by the Royal
Medico-Psychological Association (RMPA), I faced the hurdle of obtain-
ing a senior registrar job, the prelude (after three or four years) to applying
for consultant posts in the NHS.
In the 1950s and most of the 1960s, there was a strict racial, and
less-strict gender glass ceiling for senior registrar (SR) posts, especially
when they were based at teaching hospitals in London. At this point I
struck lucky—a Jewish consultant I had worked under looking after
inpatients at the base hospital in Epsom and helping with outpatient clinics
at the London Jewish Hospital in East London, recommended me to a
colleague and friend at the London Hospital. I was appointed SR at the
London Hospital, and learned later that this particular consultant, who had

vii
viii PREFACE

clearly spoke up for me at the appointments committee, had himself been

the first Jewish doctor to be appointed as a consultant there. This job
suited me perfectly because I came to be quite attached to the area that the
patients came from, but also because I was able to get funding (through
contacts I made) to begin a research study I had planned on socio-cultural
aspects of depression among Jewish people in East London. Later, in the
1960s, I worked at Claybury Hospital in Woodford, Essex (where some
of the admission wards were organised along the lines of therapeutic
community principles); and finally at Chase Farm Hospital (a general
hospital) in Enfield, Middlesex.
Many psychiatric institutes in London were operating a race-based
glass-ceiling in the 1960s and early 1970s in terms of senior staff
appointments; and there were indications that black patients were dissat-
isfied with the services they received, too. In the late 1970s I became
involved in the work of the Transcultural Psychiatry Society (TCPS) in
campaigning against racism in mental health services (see ‘Transcultural
psychiatry in the UK’ in Chap. 6), both in terms of the difficulties faced by
non-white professionals and by black and brown-skinned users of the
mental health services. In the late 1970s, senior posts in psychiatry were
gradually opened up to non-white people as legal measures against racial
discrimination in employment practices came into effect, but even then
black or brown-skinned consultants were a rarity. The race-based glass
ceiling at the IOP was not broken until the mid-to-late 1990s, when in the
course of a few years, three senior posts were filled by two psychiatrists of
Asian origin and one of African-Caribbean origin. Significantly, none
of them had participated in the work of the TCPS—it is likely that they
would not have attained their posts at the IOP if they had done so—but
their good fortune may well have had something to do with the work done
by the TCPS. In fact one of these psychiatrists told me much later that he
thought the work of the TCPS opened doors for him.
In 1986, I was invited to serve on the Mental Health Act Commission
(MHAC), a government inspectorate established under progressive new
mental health legislation in 1983. There I met and worked with several
white people to highlight issues of discrimination and injustice in the
mental health services; and I discovered how black professionals who
reached higher levels in the mental health field often preferred not to get
involved in such activities—mainly because they were afraid for their career
prospects. I was fortunate to become chairman of the commission’s (then)
influential standing committee on race and culture, which devised its first
 PREFACE ix

policy on race following episodes of overt racism that had actually occurred
within the MHAC itself (see ‘Illustrations of institutional racism’ in
Chap. 6). Unfortunately, when we discovered serious problems in patient
care, all that we could do in the MHAC was to report the matter to the
managers of the hospital for action to be taken, and then make general
recommendations for improvement, or hope for top-down action to be
implemented as a result of our including suitable comments in the annual
reports that were delivered directly to Parliament. I learned a lot from my
service on the MHAC about how psychiatry was experienced by people
who were caught up in the system, especially if they were black—some-
thing that informed the rest of my time in the discipline. One thing I found
difficult to understand was why and how racism has persisted in Western
culture for so long; and in particular how it was that psychiatry and clinical
psychology, the disciplines that informed the mental health system, a
supposedly medical system, had come to be as they were—that they were
so often experienced as racist by people who use these services. So, while I
did the best I could in alleviating the oppression that people using the
mental health services felt (which was not much because for much of the
time I had to adhere to what I felt was a flawed system), I read about its
origins and background, integrating what I found out with my observa-
tions and personal experiences of the system itself. This book is an attempt
to share my thoughts in the form of a historical account.

London, UK Suman Fernando

 ACKNOWLEDGEMENTS

I am indebted to works of scholarship in the fields of history, psychology,

psychiatry, religion and sociology, especially those works that take a critical
approach to psychology and psychiatry and indeed to race and culture; and
those that cut across disciplines. In particular I would like to express my
appreciation of some classics in the field of race and culture, namely the
works of Frantz Fanon, Stuart Hall, Edward Said and Homi Bhabha; and
the book that first led me to examine the background to racism in
psychiatry—Alexander Thomas and Samuel Sillen’s Racism and Psychiatry,
the Black Patient—Separate and Unequal, published in 1972.
I have included in my book a few personal accounts and true stories in
order to illustrate the ways in which the personal is political and vice versa;
and I wish to acknowledge the support and advice I received from col-
leagues and friends during some of the incidents that I describe. All in all, I
have had the support throughout my writing career of numerous col-
leagues and friends, especially people I worked with in the Transcultural
Psychiatry Society (UK) for over twenty years until it was disbanded by
mutual agreement in 2008. And I am grateful to many colleagues in the
field of mental health for their encouragement whilst writing this book—in
particular I wish to mention the support of Roy Moodley and Martha
Ocampo of Toronto. Finally, I am grateful to Megan Laddusaw,
Commissioning Editor and Christine Pardue, Editorial Assistant at
Palgrave Macmillan for their patience, advice and help in taking this book
to completion, and to my wife Frances and daughter Siri for their support
and encouragement during its writing.

xi
 CONTENTS

1 Introduction 1
References 9

2 How ‘Race’ Began, and the Emergence of Psychiatry

and Clinical Psychology 11
2.1 Race Thinking 12
2.2 Exploration, Colonialism, Race-Slavery 12
2.3 The European Enlightenment 17
2.4 Scientific Racism 19
2.5 Origins of Western Psychology and Psychiatry 20
2.6 The Scientific Paradigm 23
2.7 Biologisation of Mind 26
2.8 Sociopolitical Context 27
2.9 Limitations of Knowledge 30
2.10 Modern Psychiatry and Clinical Psychology 33
References 34

3 Race Thinking and Racism Become the Norm 39

3.1 Effects of Colonisation 39
3.2 Power of Racism 41
3.3 Distortions of History 43
3.4 The Arts and Nineteenth-Century Sociology 45
3.5 Nineteenth-Century Psychology and Psychiatry 46
3.6 Inherited Instincts 48

xiii
xiv CONTENTS

3.7 Race Psychology 49

3.8 Mental Pathology and the Construction
of Race-Linked Illnesses 50
References 54

4 New Racisms Appear in the 1960s 59

4.1 Transformations After WWII 59
4.2 American Social Studies 65
4.3 Black Protest in the UK 69
4.4 Definitions of Racism and Race 71
4.5 New Racisms in the UK 74
4.6 Racist IQ Movement 76
4.7 Alleged Mentality of Black People 78
4.8 Racism in Cultural Research 82
4.9 Conclusions 84
References 86

5 Racism in a Context of Multiculturalism 91

5.1 Discrimination, Diagnosis and Power 91
5.2 Ethnic Issues in Mental Health Services 93
5.3 Racialisation 95
5.4 Racism in ‘Psy’ Research 98
5.5 Manipulation of Research Findings 100
5.6 Explanations for ‘Schizophrenia’ in Black People 103
5.7 Racialisation of the Schizophrenia Diagnosis 105
References 106

6 Struggle Against Racism in the UK 111

6.1 The Macpherson Report 111
6.2 Transcultural Psychiatry in the UK 114
6.3 Action on Apartheid 117
6.4 Action by Black Professionals 117
6.5 The Black Voluntary Sector (BVS) 119
6.6 Institutional Action 121
6.7 Government Action 122
6.8 Illustrations of Institutional Racism 124
6.8.1 The MOST Project 124
6.8.2 The Ipamo Project 126
 CONTENTS xv

6.8.3 Racist Exploitation of a Black Organisation 127

6.8.4 Racism in a Government Body 128
6.9 Race Matters in Professional Associations 130
References 132

7 Persistence of Racism Through White Power 135

7.1 Controlling Racialised Minorities 136
7.2 Employment in the Mental Health System 138
7.3 Institutional Racism in the Department
of Health (DOH) 140
7.4 Black People in White-Dominated Systems 143
7.5 How Whiteness Operates 145
7.6 Privilege and Power 146
7.7 White Knowledge 148
References 150

8 Racism Post-9/11 153

8.1 Diasporic Identities, Nationalisms and Multiculturalism 154
8.2 Obama Years 156
8.3 Rise of the Political Right 158
8.4 Civil Unrest 161
8.5 Changes in the Field of Mental Health 161
8.6 Racist Conclusions of Psychiatric Research 162
8.7 Racism of a Psychology Report 163
8.8 Islamophobia 167
8.9 The ‘Psy’ Disciplines and Islamophobia 169
8.10 Conclusions 173
References 173

9 Racism with the Advent of Trump and After Brexit 181

9.1 New Era of Unashamed Racism? 182
9.2 Why Racism Has Persisted 184
9.3 Future of the ‘Psy’ Disciplines 185
9.4 Conclusions 186
References 189
xvi CONTENTS

Bibliography 193

Author Index 197

Subject Index 203

 LIST OF FIGURES

Fig. 2.1 Historic context of psychiatry and psychology 14

xvii
 LIST OF TABLES

Table 2.1 Scientific paradigm 24

Table 4.1 Theories of black racial inferiority 66
Table 5.1 Racial inequalities in the UK 94
Table 7.1 Ethnicity and diagnosis 137
Table 7.2 Ethnicity and ‘stop and search’ 137
Table 7.3 British citizens in prison in England and Wales 137
Table 7.4 School exclusions 137

xix
 CHAPTER 1

Introduction

The notion of ‘race’ has been problematic for a long time and it has bred
racism—an undoubted reality for many people from (what these days are
called) racialised groups (see ‘Racialisation’ in Chap. 5). Today, racism is
like a sin, everyone seems to be against it—or at least says they are. Yet only
fairly recently—even into the 1960s—some people who saw themselves as
respectable were not ashamed to be racist. As a newly-wed couple in the
early 1960s, my wife and I presented at a hotel in the town of Teignmouth
in the English county of Devon and asked for a room at an expensive hotel.
The landlord politely informed me that he operated a ‘colour bar’ because
(according to him) that was what his clients wanted. That was in the early
1960s, before the 1965 Race Relations Act (Hepple 1966) that outlawed
racial discrimination—the law was strengthened later, the Race Relations
Act (1976) making it unlawful to refuse hospitality at a hotel on the
grounds of race. The 1965 Act set a standard of behaviour that helped
promote the changes in public attitudes that followed over the next two
decades. It is well to remember that the 1960s was the time of legalised
race segregation in the USA—it was the Jim Crow era (see ‘Exploration,
colonialism, race-slavery’ in Chap. 2), so the overt racism in UK at the time
was relatively mild in comparison to that in the USA—but yet it was
unashamed and in one’s face. In late 1960s into the 1970s, a feeling of
shame about being racist gradually infiltrated public behaviour in the UK,
although it was often merely about being seen to be racist, and many people
became careful in the language they used (later called ‘political correctness’
of language—see Weigel 2016).

© The Author(s) 2017 1

S. Fernando, Institutional Racism in Psychiatry
and Clinical Psychology, Contemporary Black History,
DOI 10.1007/978-3-319-62728-1_1
2 S. FERNANDO

In the 1960s, I became interested in researching cultural issues in mental

health field. Since I was working at the London Jewish Hospital I was
persuaded by a colleague to focus on (and interested in) Jewish people and
fortunate to be supported by the new professor of psychiatry at the London
Hospital in organising a research project into cultural aspects of ‘depression’
that studied people who had been diagnosed as depressed. Essentially, I
planned to compare Jewish and non-Jewish individuals in terms of nominal
religious practices and ways of living. The project took me about four years
to complete and was successfully presented for a MD degree much later.
The subjects of research were Jews and non-Jews who had been born in a
defined part of East London and were from the same social-class back-
ground—in other words the groups were controlled for social background.
However, as I talked with the people concerned (the subjects of the
research) it seemed to me that the experience of the Jews I interviewed had
been very different to that of the non-Jews. The former had experienced the
dreadful anti-Semitism that was prevalent in East London in the first half of
the twentieth century. In fact the background life experiences of the two
groups (Jews and non-Jews) were very different—so in this respect they
were not controlled for social background. I realised then that studying
cultural differences cannot ignore racism in people’s experiences—‘race’ and
‘culture’ always interact and must be taken together. This lesson stayed with
me ever since and has affected much of my later research and writing.
Racism reappears again and again in various manifestations in the UK, if
not the world over. And it is the UK, and to a lesser extent the USA, that I
focus on in this book, looking in particular at mental health services and the
two disciplines that underpin these services—clinical psychology and psy-
chiatry (which I sometimes refer to as the ‘psy’ disciplines). I have been
able to approach the writing of this book from within (as it were) the field
of mental health because I was a practising psychiatrist for over twenty
years in a multicultural area of London, and was drawn into exploring the
ways in which racism was manifested in clinical work, including my own,
and, more seriously, the way that mental health services were experienced
by black and minority ethnic (BME) people (the acronymic term BME is
applied to people seen as the racial ‘Other’; racialised people, black people
in the language of 1960s UK (see ‘Racialisation’ in Chap. 5).
Although the notion of ‘race’ as a reliable attribute of human
beings is problematic (hence the inverted commas round the word in this
instance), it seems to persist as a sociopolitical phenomenon (Omi and
Winant 1994, 2015) and it is commonly accepted as a social reality
 1 INTRODUCTION 3

(see ‘Definitions of racism and race’ in Chap. 4). Racism used to be

specifically about discrimination, implying the inferiority or even oppres-
sion of people designated as belonging to a ‘race’ apart from the ‘white
race’—and hence racism is always associated with the notion of white
supremacy (see ‘Privilege and power’ in Chap. 7)—but today (2017) it
refers mostly to a variety of behaviours and attitudes expressed often by
gesture, innuendo or just by the way a person looks; it does not necessarily
refer to overt racist behaviour such as physical attacks, spitting or hurling
racist epithets, although of course these would be definitely racist and are
unfortunately becoming much commoner now in the UK than they were a
few years ago, in my experience. The power and significance of the look is
amplified by Fanon (1952) in Black Skin, White Masks.
My academic and professional background is in the field of mental health
and my interests have long been centred on the way the clinical disciplines of
psychology and psychiatry have developed in Western culture, especially in
their cultural and social roots and dimensions; and on the history of mental
health, especially the services for providing help and support for people who
are deemed to suffer from (what are commonly called) mental health
problems. Throughout most of my professional life, nearly all of it spent in
the UK, I have been mindful, sometimes intensely so, of the interplay
between individual personal experiences, professional responsibilities, the
lives of patients and clients (of the mental health services) and the
sociopolitical forces and activities that connect with mental health work. In
other words, the personal, the political, the academic and professional have
meshed together in much of my adult life. And in writing, I find it difficult to
separate them out into silos. So my approach to the writing of this book is
(a) to look at the history of ‘race’ and racism, and how they impact on the
clinical practice of psychology and psychiatry (the ‘psy’ disciplines); and
(b) to explore the issues involved by presenting a mixture of historical facts
researched with as much care as I can muster, from a number of sources; the
lessons I learned from clinical experiences and from talking with people I
have met as users of mental health services; and mindful observations of real
life in the politics of the British mental health system—all told against the
background of a wider social and political context (mainly that in the UK)
and told, as much as possible, like it is.
The rest of the book is set out vaguely in terms of a sequence of events
and happenings starting from the ‘beginning’ (another problematic
notion) and building up to the present, as one would expect a history book
should be. Bearing this in mind, my approach (stated above) means that
4 S. FERNANDO

there will be toing and froing across time, but hopefully with adequate
cross-referencing. The book traces in broad outline how racism grew in
importance, then went underground (as it were) by becoming recon-
structed in ever newer forms, interacting all the time with the anti-racist
forces in society; while the original biological understanding of the notion
of race changed, to become socially and politically constructed.
Racism was one of the powerful forces that drove the slave ships on the
prolonged Atlantic slave trade, and almost concurrently (and for even longer)
underpinned the massive project of colonial conquest, exploitation and often
appropriation, by white Europeans, of lands and property (including the
intellectual property) of people seen (by whites) as not being ‘white’—almost
as if they (the whites) felt these ‘other’ things and ‘other’ people belonged to
white people; even the history of humankind came to be seen (by white
people) as belonging to them. Something often forgotten is that racist ideas
were heard loud and clear at the dawn of modern European culture at the time
of its so-called ‘Enlightenment’, and was (and still is) deeply embedded in
what were—and possibly still are to a great extent—‘European values’.
Certainly racism was one of the values that European nations exhibited right
up to the mid-twentieth century, but since then (roughly since the end of the
Second World War, or WWII) European culture has steadily moved away
from its racist inheritance, albeit with a revival during the past decade which,
hopefully is a temporary setback. Cultural shifts that occurred in Europe
during the Enlightenment gave rise to (among others) the professional fields
of psychiatry and clinical psychology—a duo that developed in tandem—
both fields being akin to medicine in their concern with the observation and
treatment, often referred to within the clinical professions as ‘management’,
of people called ‘patients’ or ‘clients’.
Although after WWII and the fall of European colonial empires, racism
was challenged in many walks of life in Western countries, racism in ever
newer forms continues to impact on many aspects of Western society
(including the activities of the ‘psy’ disciplines), having become largely
institutional and subtle in its expression and manifestation (see ‘Definitions
of racism and race’ in Chap. 4). Also, more recently, racism has extended
to affect groups of people apart from those traditionally seen in European
societies as the racial ‘Other’, such as immigrants, refugees and people seen
as ‘Muslims’, Romany communities and so on. To a greater or lesser extent
these groups are racialised (see ‘Racialisation’ in Chap. 5). And, during the
past decade—perhaps since the attacks on the twin towers in New York
(9/11) and the so-called war against terrorism—there has been a rise in
 1 INTRODUCTION 5

Euro-America of less subtle forms of racism, racism in the form of (for

example) racist attacks supposed to punish terrorists, or terrorist sympa-
thisers seen as ‘radicals’, or just people seen as representing them in some
way (the notion being sometimes fanned for political reasons) by being
immigrants—hence attacks on immigrants. Along with this, there has
recently (2001 onwards) been a greater tolerance in official circles, at
middle-class dinner tables and in professional institutions, of institutional
racism including subtle allegorical references to ‘race’. All this, while an
impression has been created by the powers to be that the Western world is
no longer racist—that it is ‘post-race’, represented by the fact that
Americans elected a black man as president in 2008, and then, to the
surprise of much of the world, a racist white supremacist eight years later
(see ‘Obama years’ in Chap. 8 and ‘New era of unashamed racism?’ in
Chap. 9). The rest of this book covers many of these matters briefly, but I
hope succinctly, and attempts to see their connection to the ups and downs
of racism in the ‘psy’ disciplines.
Chapter 2, ‘How “Race” Began, and the Emergence of Psychiatry and
Clinical Psychology’, traces the development (a) of the notion of ‘race’
through to its firm embodiment in racism via ‘race thinking’; and (b) of the
disciplines of clinical psychology and psychiatry through the study of
‘madness’, in a context of the confinement of various types of people who
were socially excluded and forced into asylums. The chapter touches on
how racism was rooted in the Atlantic slave trade, and vice versa; how
slavery provided the wealth for the economic power that generated colo-
nialism; and how racism became diversified and stabilised through the
near-total domination of the world by European power. It describes in
brief how the values attributed to ‘reason’ and ‘unreason’ in the way people
(in the West) lived their lives, changed at around the time of the
Enlightenment; how beliefs and behaviours that were deemed unaccept-
able and alien to polite (white-European) society became symptoms and
pathologies in models of illness or formulations of deviance concocted by
doctors (‘alienists’ and ‘mad-doctors’, later called psychiatrists) and clinical
psychologists; how sociopolitical-cultural structures came into being in the
West to become (what we now call) clinical psychology and psychiatry; and
finally how the biomedical ways of interpreting the lived experience of
human beings has become embedded in Western culture—together with,
and bound up with, racism.
Chapter 3, ‘Race Thinking and Racism Become the Norm’, begins by
describing the nature and power of the colonial projects around the world