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This essay aims to critically analyse the Sir John Blofeld inquiry report into the death of David Bennett in 1998, through the theme of institutional racism. In order to achieve this, I will give a brief background to the inquiry chaired by Blofeld in 2001. This will enable me to reflect upon the various aspects of this particular case and build a context for the inquiry. I will look at explanation of evidence based practice to social work and seek to learn from the report in order to inform my own practice. The choice of the above theme reflects my belief in anti-oppressive and anti-discriminatory as a good social work practice.
Mr David Bennett was an African-Caribbean. He suffered from schizophrenia. He had been receiving treatment for his mental illness for some eighteen years before the date of his death. On that evening, Mr David Bennett had been in an incident with another patient who was white. During that incident, each man struck out at the other. Mr David Bennett was also the recipient of repeated racist abuse from the other patient. After this incident, Mr David Bennett was moved to another ward. While in that ward he hit a nurse. He was then restrained by a number of nurses and a struggle developed. He was taken to the floor and placed in a prone position, face-down, on the floor. During the prolonged struggle that then continued he collapsed and died. The first part of the Inquiry covers the whole period of Mr David Bennett’s illness, the events leading up to his death and certain other events that took place during the hours and days following his death.
I will provide a definition of evidence based practice. Evidence based practice is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individuals” (Newman et al 2005, P: 4). It calls for decision making that is considered rather than reactive. Therefore professional should be equipped with the knowledge that will enable them to discharge their responsibility effectively, and they must continue to learn, and put that learning in practice. Decision making at an individual level must also be informed by professional judgement and intimate knowledge of the client’s personal narrative. Evidence-based practice cannot deliver certainties just increase probabilities (Newman et al 2005).
Inquiries have been crucial to raise society’s awareness about social problems that disadvantaged groups of people face. For practitioners, the reports of these inquiries have indentified some valuable lessons to be used to refine policies and everyday practice. The findings from MacPherson report into the death of Stephen Lawrence and the Ritchie Inquiry into the care and treatment of Christopher Clunis found institutional racism in the mental health and police. The same problem identified by Blofeld inquiry into the death of David Bennett.
Benefits of public inquiry, according to Brammer (2007, P: 291), include its ability to “ascertain the facts of the case; learn lessons for the future and to meet public concern”. Prior to the death of Bennett, there had been a number of deaths of BME people in psychiatric custody that had concerned the Institute of Race Relations. These included the death of Orville Blackwood in Broadmoor Hospital in 1991 through to the death of Veron Cowan at Blackberry Hill Hospital in Bristol in 1996 (Athwal,2004). The critical atmospheres of inquiries and media attention lead to the belief that there was institutional racism. This put the activities of psychiatrics are usually under scrutiny during public inquiries into the death of BME and as a result, such inquiries have had an impact upon their morale in practice.
I will now define institutional racism. The definition set out in the Macpherson Report (1999) is:
“Institutional racism is the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping, which disadvantage minority ethnic people.”
Institutional racism is a systematic set of patterns, procedures, practices, and policies that operate within institutions so as to consistently penalise, disadvantage, and exploit individuals who are members of non-White groups (Better, 2002).
Institutional racism in mental health hospitals could be evidenced in a number of ways. Failing to provide BME patients with an adequate diagnosis, not providing them with a coherent treatment plan, not offering appropriate treatment and failing to meet needs are common examples. As Singh concludes:
“Such failures occur repeatedly over many encounters with the services, and several clinicians individually and collectively contribute to the poor decision-making. These experiences are replicated nationally for patients from ethnic minority groups.” (Singh, 2007, p: 363).
In the case of David Bennett inquiry 2003, all external experts agreed unanimously that institutional racism exists in psychiatric services. In UK, racist practice is not openly or publicly encouraged, according to Race and Relations Act. The public is concerned with institutional racism (the inequalities) in mental health, and there is evidence that Black minority ethnic (BME) people are marginalised in mental health services.
When black people come into contact with professionals such as the psychiatrists or health workers, they focus inappropriately on culture, and ethnicity at the expense of sound clinical judgement and this is where BME Patients experience misdiagnosis and poor health care. In case of David Bennett, his early contact with mental health services, the psychiatrist (Dr Feggetter) was dismissive and believed that his problems were due to cannabis intoxication. From 1980 to 1985 professionals thought that it was his use of cannabis that was causing the problem rather than this mental ill-health, but he was diagnosed later as suffering from schizophrenia. Therefore, the stereotypes can form the basis of misdiagnosis. Pilgrim and Rogers (1999) are of the view that professionals appear to have a limited capacity to recognise psychiatric disorders in black patients compared with other patients. Young black men are misdiagnosed by the mental system, which tends to operate on the basis of limited or inadequate knowledge of black communities and using stereotypical expectations of young black men’s behaviours (Fernando, 1998).
Experts estimate that black people are three times more likely to be diagnosed as schizophrenic but less likely to be diagnosed with depression (McKenzie 1999). Also, there is evidence that black men were more likely than others to be held in secure in-patient environments. Pilgrim (2005, P: 32) suggests that racial biases mean black people are disproportionately dealt with by specialists mental health services, and as these services are characterised by coercive practices, one could interpret this as institutional racism. More so, on the clinical side of treatment, In relation to Bennett’s treatment at the Norvic Clinic, the report refers to actions by professionals which can be seen as driven by institutional racism. Dr Sagovsky related that Bennett was on a particularly high level of anti-psychotic drugs as he was seen as especially dangerous (Bennett Report, 2003, P: 10), a view that may have been linked to Bennett’s physical appearance. Ultimately, this combination of drugs was described as ‘troubling’ (Bennett Report, 2003, P: 26) by the inquiry, even if it could not be directly linked to Bennett’s death
Sandhu (2007) argue that many people from BME backgrounds complain that mental health services focus primarily on medication maintenance and control therefore; appropriate chances for recovery are limited. The diagnosis applied to the black patients were, however, significantly different from those applied to the white patients. A research by Littlewood and cross (1980, p: 121) found that stereotyped attitudes led to assumptions that ECT is suitable for black patients than white patients.
Blackness and madness plus dangerousness. 220
In addition to that, black patients are dealt with impartially in the psychiatric units, their level of dangerousness is assessed objectively on the basis of information provided and likelihood of mental illness based on history. Bennett was a very athletic young man, staffs were frightened of him. These misconceptions about black people that have also become embedded in mental health practices often combine to influence the way in which mental health services assess and respond to the needs of black people. Restraints
Brammer (2007, P: 467) is of the view that there is “evidence that practice race is considered an index for dangerousness in mental health field”. Staff working with Bennett perceived his race as dangerousness, and so the staff had to use too much force to restrain him, by pinning him down for long ‘when they should not have done so. To some sources; it is a ‘serious failure of training’ that no time limits were given for the restraint of a person in a prone position, but to others its racism. Fernando (2002) the dangerousness of a BME patient is determined by racial stereotypes of black people while other factors are ignored. This is institutional racism, how can race determine dangerousness of patients. Fernando (2002) further highlights that the power of people working in mental health provide cover for racism to operate unchallenged. This denial of racism is common within organisations where it can be found. Collier (1999) suggests that:
“The oddest thing about institutional racism is the blindness of the perpetrators. In a racist organisation outrageous thoughts and behaviours are acceptable and all apparently without questioning….worse still the victims are caught too as they seem paralysed, unable or unwilling to protest in case they suffer more.”
One way in which institutional racism manifests itself is the over-representation of BME in compulsory admission in psychiatric units. The count me in the census for England and Wales showed higher rates of admission for mental illness and more adverse pathways to care for some BME groups and led to accusations of institutional racism within psychiatry. The keys issues identified in the Bennett report are common to discussion around BME communities and mental health, namely the high levels of compulsory detention. As Patel and Heginbotham (2007, p: 367) write: “Either there is an epidemic of mental illness among certain Black groups or there are seriously worrying practices that are leading to disproportionate levels of admission”.
A large number of people from ethnic minority are particularly likely to be detained under section 136 Mental Health Act 1983, and there are a large number of young Afro-Caribbean males admitted under compulsory detention into psychiatric hospitals. Nearly half of these numbers were referred by the police, courts of law, social workers and GP’s (Browne 1997). By 1990s, studies reported that African Caribbean males were over-represented among those formally detained in acute in patients units, and they were also up to 3 times more likely to be sectioned than their white counterparts. This supports the view that institutional racism is popular in mental health units. However, the decision to detain a patient is necessarily preceded by patient’s refusal to accept help on a voluntary basis. This is because some groups of people refuse help from psychiatric services and sometimes are non- compliant. Therefore, interpreting institutional racism as the main explanation for the excess of detentions among ethnic minorities adds little to debate and prevents the search for real causes of these differences.
Cultural needs. 470
Institutional racism is about how organisations acknowledge the diversity of their client base and meet their cultural needs.
The Bennett Report provided a number of examples of how these needs were not met with Bennett. For example, Dr Stanley also said that Bennett did not wear dreadlocks and yet she knew he was Rastafarian, and in most cases his religious beliefs and cultural were not mentioned through his meetings with different consultants. Staff within the system failed to understand that ignorance or thoughtlessness can lead to a form of institutional racism just as damaging as overt deliberate racism therefore; one fits with the Macpherson definition of inquiry.
Further more, there is a wide-spread perception that mental health services do not have sufficient understanding of the complex and diverse religious, cultural and traditional needs of BME people and that this constitutes institutional racism as defined by Macpherson report. Dr Feggetter noted that Bennett’s cultural needs were not addressed, but patients were treated as human beings. There is a need to treat each person as an individual rather than a group. Fernando (1986) shows how the effects of racism can result in depression through experience of rejection, loss and hopelessness. It may also create a bias to depression through a feeling of hopelessness and inability to exercise any control over external forces. Racial discrimination is an obvious cause of stress in the lives of people from the ethnic communities, however, any policies and practices measures to address the diverse needs of BME groups including appropriately sensitive environments taking into account patient’s dietary, religious and cultural backgrounds.
Sewell (2009) differences in culture whatever it is, may lead to real differences in understanding and communication of certain experiences. It is vital to remember that there are some people within a BME group who may adhere to their cultural practices while others may not.
The report argued that Bennett’s racial, cultural or social needs were not met within the mental health system and that it failed to protect him from what were at times high levels of racial abuse from other patients. Racial harassment is a serious problem, and it is important that service providers should have clear policies and procedures to deal with inter-patients racial harassment. The report stated that staff within the system failed to understand that ignorance or thoughtlessness can develop a form of institutional racism just as damaging as overt deliberate racism. Another telling point in the report that can be seen as evidence of institutional racism is the finding that Bennett was “a man who was treated at times with a degree of intolerance and at times as if he were a nuisance who had to be contained” (Bennett Report 2003, P:12). In the events leading up to Bennett’s death, staff failed to adequately address the sustained racial abuse that Bennett received from another patient and also apparently ignored Bennett’s complaints that he was a black man trying to cope in a white environment.
Bennett was bound to feel acutely sensitive’ and particularly if their perception is that no action may be taken to prevent racist abuse. What is relevant here is the point that institutional racism does not have to involve direct racism by staff or members of an organisation – it can equally stem from an organisational failure to address racism that might come from other service users or clients.
Criticism of the theme
In this section will look at the impact of institutional racism on the service user: This accusation of racism as an explanation for these findings is not productive, as It leads to several damaging consequences for the profession, ethnic minority groups and most crucially for ethnic minority patients. It is the psychiatry organisation which is discriminatory but not individual psychiatrists. Therefore, we must focus on the underlying reasons whatever those are, and try to understand the multifunctional interrelated issues which lead to the cited high admissions and detention rates for some groups in society.
The different rates might also be a consequence of discrimination and racism that ethnic minority people face in Britain. It would not be surprising if the multiple victimisation that some are subjected to, led to mental distress (Hudson 1992, 4-5). Thompson (2006, P: 80) asserts that BME people become mentally ill as a result of the systematic erosion of their capacity to deal with multiple oppression. This explains why BME patients in psychiatric units become violent in the psychiatric units than when they were admitted. When we look at the case of Bennett racial abuses from other patients and control agitated him.
Institutional racism acts like a self fulfilling prophecy by contributing to mistrust of services by ethnic minorities, thereby leading to delayed help seeking with increased use of detention and coercive treatments for ethnic minority patients.
BMH (2009) agree that new horizons offers the opportunity to ensure that the failures highlighted within the Bennett inquiry report are taken forward and addressed through this new strategy. It goes onto suggest that there must be moves away from the medical model and admitting a disproportionate number of black patients into secure psychiatric settings. The rights and health care needs of BME are less likely to be taken seriously than those of white clients.
A key element of the government’s response to the Bennett Report has been the development of the Delivering Race Equality in Mental Health Care (DRE) which aims to achieve equality and tackle discrimination for all BME mental health service users. Amongst the aims of DRE are: a reduction in fear of mental health services among BME communities; reduced rates of admission of BME people to psychiatric inpatient units; reduced rates of compulsory detention for BME service users; a more active role for BME communities and service users in training and development of mental health policy and; the provision of a mental health workforce and organisation capable of delivering appropriate and responsive mental health services to BME communities (DOH, 2005). DRE is a positive initiative and is clearly aimed at clearing out any forms of institutional racism within mental health services.
Looking at the implications of Bennett inquiry in relation to social work practice the key tools are to combat institutional racism within mental health services has to be the use of anti-discriminatory practice. This requires social workers to understand that discrimination and oppression are often central to the situations that they encounter (Davies 2003). Within the arena of mental health, anti-discriminatory practice entails moving out of an ethnocentric frame of reference and taking account of the fact that we live in a multi-ethnic society. On a wide level, justice, equality and participation are important concepts of anti-discriminatory practice (Davies 2003).
The code of practice requires that people to whom the Act is applied should be given respect for their qualities and diverse backgrounds as individuals and be assured that account will be taken of their age, sex, gender, social ethnic cultural and religious backgrounds but that general assumptions will not be made on the basis of anyone of these characteristics (Ninth Biennial report1999-2001, p: 63).
In mental health participation might involve service users in the planning, coordination and evaluation of services to provide opportunities for empowerment and to ensure that services are culturally appropriate and responsive. To use the mental health code of practice 08 ‘participation’ principle that service user should be involved in planning, developing and reviewing their treatment. It was cited that professional working with Bennett did not involve him at all.
Empowerment within mental health can also refer to ensuring that BME service users are able to access information about services and go on to receive such services. Ideas about working in partnership with service users are also important here – referring back to the Bennett report, there was little in the way of working in partnership with Bennett during the time of his illness and little evidence of empowerment or anti-discriminatory practice to try and eliminate the elements of racism within service provision (Burke and Dalrymple, 2006).
The GSCC Codes of Practice lay out ways in which both social workers and management can act to combat institutional racism. The codes for social workers state that they must use “established processes and procedures to challenge and report dangerous, abusive, discriminatory or exploitative behaviour and practice (3.2 GSCC codes of practice) and also – crucially in challenging institutional racism. they must not condone any unlawful or unjustifiable discrimination by service users, carers or colleagues. (5.6 GSCC codes of practice). Social care employers must also establish processes under which social workers can report dangerous, discriminatory or abusive behaviour and have methods to deal with these reports (4.2 GSCC codes of practice). Such processes were clearly lacking at the Norvic Clinic when Bennett was a patient and it is important that organisations have channels for staff at all levels to challenge any forms of racism by colleagues of service users. As indicated previously, social workers working with BME service users with mental illness need to have an understanding of cultural differences between this service user group and white people. They must also treat BME service users and white service users in the same way. For example a black man presenting with possible mental illness may be talking loudly – common symptoms of mental illness. However if a professional simply sees an angry black man there may be an incorrect judgement that trouble or problems may follow and an inappropriate response might be the result. (Bennett Report 2003, P: 48).
Practitioners need to examine their own attitudes and ask themselves whether their practice shows any evidence of indirect discrimination, however anti-discriminatory they may feel that they are as an individual. For example, do practitioners misinterpret cultural differences as mental health symptoms, do they believe there is a link between immigration and mental illness or could they be inherently racist and see some service users as posing more of a risk simply because they are not white?. The Bennett Report found that institutional racism existed within UK mental health services and there is still work required to eliminate this. Collier (1999) asserts, “Institutional racism must be stamped out, but leaving it to individuals is not to be recommended. Mechanisms must be put in position to make the change corporate…nothing less is unfair or unworkable” This is the key point – institutional racism is far bigger than the actions of a few individuals and beyond the remit of individuals to resolve. Tackling inherent institutional racism across a large organisation needs large scale change over a period of time. The recommendations of the Bennett Report have pointed the way forward and DRE looks to build on this. Change to attitudes towards BME service users must be driven from the top downwards and be embedded in all areas of the organisation. Advocate for service user who feels that they are wrongly detained in hospital under MHA1983, inappropriate use of power under MHA83 is a trap, for social workers to fall into if they are not sufficiently aware of diversity issues of psychiatry (Thompson 2006).
I have learned that I should be able to challenge racism, and should always recognise and respect diversity when working with service users. I should endeavour to always reflect on my practice using own initiatives, involve service user’s and their families in formulating care plans, be able to work as a team member and continue to update myself in current guidelines, policies and procedures and more so, work in anti-discriminatory and anti-oppressive manner.
In conclusion; ‘Institutional racism’ could possibly explain why BME higher prevalence within in-patient areas of the mental health service. On the other hand, it is clearly apparent that institutional racism is still at large, what is needed here is a re-assessment of the mental health service, including new coping strategies for individuals from BME and support community wide. The breakdown of stereotyping will be necessary for both the medical professional and the wider community. It is clear that staff in mental health units have in the past ignored cultural values of ‘others’.
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