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How the Mental Health Act perpetuates systemic racism

Black people are four times more likely to be sectioned and detained in hospital against their will. Laws are finally being reformed.

By Sarah Dawood

In April 2021, Hannah was pinned down and restrained by six male staff at a psychiatric hospital. She was left traumatised.

“It was horrendous,” she tells Spotlight. “I had nightmares about it for weeks on end. I remember curling up in the foetal position on the floor and crying myself to sleep. I didn’t leave my room for two days. I couldn’t move, I couldn’t eat.”

This was the second time Hannah, a 22-year-old mixed-race woman, had been physically restrained while detained on a mental health ward. She was also subjected to chemical restraint, by being injected with a sedative.

Both times, Hannah had already been extremely mentally unwell. Staff had restrained her after she attempted to harm herself by strangulation with a ligature. “Staff said they shouldn’t spend time verbally de-escalating me because I’d ‘probably turn violent’ or ‘I may hit them’,” she says. “But I’ve honestly never shown an ounce of aggression.”

Since 2019, Hannah has been sectioned six times by the police and healthcare professionals, once being detained in hospital for 45 days. She lives with borderline personality disorder, anxiety, depression and post-traumatic stress disorder. Prior to being sectioned for the first time, she says that she had repeatedly asked her GP for help.

She has now been able to start an 18-month therapy programme. “I had been asking for therapy for [four] years and had contacted my local MP. I’d been in hospital ten times before I was offered it. One of my [white] friends was offered it after her first admission,” she says.

From what she has seen as an in-patient, black and mixed-race people are vastly over-represented on mental health wards, will be detained for longer, and are treated more brutally. “I’ve been on wards where black men have died after being held down for too long or injected too many times,” she says. “It’s soul-destroying. Someone comes in for help and they leave in a body bag.”

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Hannah’s story reflects a pattern of systemic racism across NHS mental health services that is borne out by available data. The Mental Health Act 1983 provides powers to section people against their will if they meet the necessary criteria following assessment by a team of health professionals. This includes if their safety or someone else’s safety is at risk, if a doctor thinks they could get worse if they are not admitted, or if they have started new medication and need to be monitored. Official data shows that black people are over four times more likely than white people to be sectioned and detained under the act, subjected to restraint and held in isolation. They are also over ten times more likely to be subject to a community treatment order (CTO) – supervised treatment in the community where you could be returned to hospital if you do not uphold set conditions.

This trend is indicative of similar discrimination across wider society: black people are nine times more likely to be stopped and searched by police. Between 2008/9 to 2018/19, they accounted for eight per cent of UK deaths in police custody, despite only making up three per cent of the population. The recent case of Child Q, the 15-year-old who was strip-searched at her school after a teacher wrongly assumed she had cannabis, demonstrates the vulnerability of children to such systemic prejudice.

Campaigners have also raised concern about the treatment of people with learning disabilities and autism under the Mental Health Act, calling for change. An independent review led by psychiatrist Simon Wessely concluded in 2018 that the act was desperately in need of reform.

Wessely, who has conducted psychiatry research since the 1980s, acknowledged in his review that people of black African and Caribbean heritage have consistently been over-represented in terms of detentions and certain mental health diagnoses, such as schizophrenia. “Now 30 years later, it is sad to record that little has changed,” he wrote. “There does appear to be more consensus that this… is related to experiences of discrimination, exclusion and racism.”

He stated that while there will be times where it is “reasonable to make a temporary infringement of liberty and autonomy”, the mental health profession has an obligation to ensure its interventions do not make people worse, that “more are made better” and that “all have their dignity respected”.

The review’s recommendations centre around safety and autonomy. “Patients must be supported to make choices for themselves,” Wessely wrote. It also includes proposals around reducing the use of force, ensuring treatment provides therapeutic benefit, and treating people as individuals by providing more tailored care. Suggestions included: new rights of appeal against compulsory treatment, such as better access to tribunals; the creation of “advance directives” (where patients can make decisions about their treatment in advance); safeguards such as rules around length of detention and better oversight by the healthcare regulator, the Care Quality Commission; improved access to long-term support; and greater representation of black people working in mental health.

Last year, the government published a white paper saying that it would take forward “the vast majority” of the review’s recommendations. It will also use evidence gathered from a consultation that took place in 2021 with patients and experts to reform the act.

A new draft Mental Health Bill is due to be a legislative priority for this year, and will eventually replace the Mental Health Act 1983. It was included in this year’s Queen’s Speech on 10 May as parliament opened its session for 2022-2023, and is still expected to include most of Wessely’s suggestions around personal choice and fair treatment. However, it is not yet confirmed when it will become law.

Exacerbated by the pandemic, NHS mental health services are under immense pressure with growing waiting lists, a lack of funding, and a record 4.3 million referrals in 2021. According to the Royal College of Psychiatrists, one in four people with mental health problems waits at least three months to start NHS treatment, and two-fifths of patients who are waiting end up contacting emergency services. The NHS also reportedly pays £2bn a year to private hospitals for mental health beds because it does not have enough.

But discrimination starts long before patients reach the hospital. Resource scarcity coupled with unequal access to services means that many people like Hannah are often extremely ill by the time they receive care. The government has committed £2.3bn per year, starting in 2023 to 2024, towards providing earlier support to prevent people reaching crisis point, as well as alternatives to detention, quicker discharges and improved community care. A new ten-year mental health plan is also in development.

After years of lobbying from campaigners, the government has also changed laws around the use of life-threatening restraint methods. The new Mental Health Units (Use of Force) Act – better known as “Seni’s Law” after Olaseni Lewis, a black British man who died after being restrained by 11 police officers in 2010 while in a hospital mental health unit – aims to curb the use of unnecessary restraint by holding staff to account. Under this legislation, mental health units have to provide training for staff, keep records on the use of force and publish annual statistics, and make patients aware of their rights. Police officers going into units must also wear body cameras.

The Department of Health and Social Care’s newly created Office for Health Improvement and Disparities also aims to “break the link between background and prospects for a healthy life”, says Gillian Keegan, minister for mental health. “We know disparities exist in mental health,” she tells Spotlight. “I am working to bring [laws] into the 21st century and ensure [they] help everyone get the best possible care.”

Shadow mental health minister, Rosena Allin-Khan tells Spotlight that the government should also speed up NHS reform through the roll-out of the Patient and Carers Race Equalities Framework – a new competency tool that will help mental health trusts provide better and more nuanced care to ethnic minorities. “There must be culturally appropriate services and the freedom for local areas to look at their specific populations [to develop] suitable approaches,” she says.

Hannah agrees that patients cannot be treated as a homogenous group. “A black person might be more unwell because they’ve dealt with something alone for so long,” she says. “They might be angry because no one has listened to them. Different communities need different care.”

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