By Dr Nuwan Dissanayaka

“Big, Black and Dangerous? Yeah, sounds about right”, Michael says with a wry smile. Michael is a patient I have known for many years. We have talked several times about how he feels psychiatric services treat Black people.

The description “Big, Black and Dangerous” is of course the subtitle of the 1993 Report of the Committee of Inquiry into the death of Orville Blackwood, a patient in Broadmoor Hospital, and of two other African-Caribbean patients. It details how Black people are more likely to have police involvement in their admissions to hospital and more likely to be detained and to receive secure care. They are more likely to be diagnosed with schizophrenia and more likely to be given higher doses of medication. They are less likely to receive psychotherapy. Worryingly the impression that these patients were “Big, Black and Dangerous” was given so frequently to the Committee that they even included it in the title, albeit with a question mark.

Black people are more likely to have police involvement in their admissions to hospital and more likely to be detained and to receive secure care. They are more likely to be diagnosed with schizophrenia and more likely to be given higher doses of medication. They are less likely to receive psychotherapy.

Over two decades later, and despite the efforts of successive governments, little has changed. Michael identifies closely with the narrative. “It was the same every time. I’d get ill and my community would turn its back on me. I’m loud and brash and the police would just arrest me. They’d take me to hospital where they’d force me to have injections. But even when I got better it was still bad. Those places make me feel angry and I don’t feel listened to or respected by the staff. The only way out is to keep quiet and pretend to be someone you’re not. When I got out I’d do everything I could to avoid (mental health) services. That is, until the police broke my door down again…” He seems unbothered by this. “You get used to it”, he shrugs.

The acrimonious circle of mistrust that Michael describes between himself and mental health services is a sadly familiar story that I have heard many times over the years from patients of Black and Minority Ethnic backgrounds. I have little doubt that this dysfunctional relationship contributes to the threefold over-representation of Black people detained under the Mental Health Act, not only in psychiatric hospitals here in Leeds but also across the country.

Perhaps unsurprisingly, the caseload of our Assertive Outreach Team, for whom I am the consultant, which supports patients with severe mental illness who “don’t engage” includes a similarly disproportionate number of Black people. Thankfully Michael is now much happier with the care he receives from us and he hasn’t been in hospital for several years.

I’d get ill and my community would turn its back on me. I’m loud and brash and the police would just arrest me. They’d take me to hospital where they’d force me to have injections. Those places make me feel angry and I don’t feel listened to or respected by the staff. 

Psychiatric research would have us believe that ethnicity per se does not lead to increased detention under the Mental Health Act but it is instead other factors which explain this disparity. These factors include diagnosis, social support and, possibly most oft cited of all, risk. Many Black patients I see would disagree vehemently. They are convinced that the assessment of the risk they are felt to pose, usually to others, is directly affected by their race.

“I think the nurses are scared of me because I am big, black and loud, especially if I swear. And the doctors just don’t understand me. They don’t get my culture and they want me to act like them. And when I get angry it’s worse for me than it is for the white patients...if you know what I mean.”

Unfortunately psychiatric studies gloss conveniently over the issue of bias, whether conscious, unconscious or institutional. For most of us, the notion that the spectre of racism may play its malevolent part in all of this is deeply unpalatable - yet there is reason to believe that even at a conscious level it may significantly influence our judgements.

I think the nurses are scared of me because I am big, black and loud, especially if I swear. And the doctors just don’t understand me. They don’t get my culture and they want me to act like them. And when I get angry it’s worse for me than it is for the white patients

A recent survey entitled “Racial Prejudice in Britain Today” found that “compared to other social attitudes, where the last three decades have seen significant liberalisation, our attitudes to race appear more stable” and that, “while it is true that a majority of the public do not consider themselves racially prejudiced, a considerable minority describe themselves as prejudiced, and there are sound reasons to believe both that the actual prevalence of racial prejudice is likely to be higher, and that some of this prejudice is of a very significant nature, such as believing that some races are born less intelligent”.

Psychiatric diagnosis is a highly contentious subject about which I have a healthy cynicism. I can trace this back to my very first training post twenty some years ago. Then a wide-eyed junior doctor, my first boss bombarded his new patients with batteries of questionnaires and their voluminous records were heavily graffitied with his hieroglyphic scrawl. It’s a moot point as to whether this near-forensic analysis yielded results that were any more valid than the practice of his peers but the fact was that in many cases these patients were later re-diagnosed. The real revelation to me however was that this change in diagnosis seemed to apply most of all to young Black men with a previous diagnosis of schizophrenia.

The inequality faced by those of Black identity in British society is a sociological quagmire. It is beyond question that Black ethnicity is linked to multiple social disadvantages. The Government’s recently published Racial Disparity Audit has unsurprisingly revealed racial disparities across areas of public life including health, education, employment and the criminal justice system. It would be a grave mistake to assume that that these are simply associations. It is surely hard to imagine how any level of ambient discrimination could not have nurtured this inequality. It is undoubtedly positive that there is an appetite to raise this inequality on the political agenda but it remains to be seen how this will translate into meaningful change.

The Mental Health Act itself is ‘colour-blind’ but unfortunately those involved in its application are not

Speaking at the Conservative Party Conference, Theresa May announced an independent review of the Mental Health Act, intended to address the “injustice and stigma associated with mental health,” and she made specific reference to the disadvantage faced by those from BME groups. Whilst we should all welcome her intention to reform this important piece of legislation it is absolutely critical that we remember that the Mental Health Act itself is ‘colour-blind’ but unfortunately those involved in its application are not.

To rely solely upon legislative reform to resolve the inequalities which plague our mental health services would be naïve, when many of those receiving those same services are telling us that racism, both individual and institutional, is alive and well. It is only by deeply listening to and acting upon their powerful narratives, which may well contain some inconvenient truths, that we can hope to offer everyone the mental health support that they deserve.


Dr Nuwan Dissanayaka is Consultant Psychiatrist for the Assertive Outreach Team at Leeds and York Partnership NHS Foundation Trust, and an Executive Committee Member at the Faculty of Rehabilitation Psychiatry, Royal College of Psychiatrists


‘Michael’ is a pseudonym for an amalgam of people Nuwan sees


Cover image: William Stitt on Unsplash