This fascinating book addresses important issues relating to forensic mental health, race and culture, and attempts to give a clearer understanding of crucial nomenclature. Differences among so-called racial groups based on genetic variations are dismissed as groundless. The authors point out that genetic differences between Caucasians in Europe, or between different tribes of Africa, are of a similar order to those between racial groups as distinguished today. A very good review of European thinking on issues of race, intelligence and emotions clearly demonstrates the lack of understanding of other cultures by some earlier European thinkers and writers, who viewed non-European cultures through European values and perspectives. However, the book largely concentrates on these negative views, and does not acknowledge how some of these naïve approaches have changed over the years, as understanding has increased.
The authors reject the existence of schizophrenia on the basis of questionable validity. Intriguingly, no alternative explanation is given for the collection of clinical features that we currently fit under the rubric of schizophrenia, which are described by patients irrespective of cultural background. Diagnoses have sometimes been made inappropriately by psychiatrists whose culture differs from their patient's, but an abuse or misuse of a tool does not necessarily make the tool itself bad. The authors argue that psychiatry continues to practise in a racist fashion in a multicultural society, but they fail to acknowledge the greater efforts now made to take into consideration the multicultural nature of psychiatric practice in the UK. The widening spectrum of ethnicity among practising psychiatrists has also led to an inevitable increase in the cognisance that is taken of cultural differences.
The disadvantages faced by mentally disordered offenders in both the criminal justice system and the health service are well reviewed. These are far greater for those who are Black because of the “mad and bad and Black” or “big, Black and dangerous” stereotypes. The inadequate facilities available in secure institutions to meet the needs of mentally disordered offenders from ethnic minority groups are considered; for example, the token nature of providing an ‘interpreter’ rather than trying to meet social, cultural, ethnic and religious needs. Efforts to make these provisions vary from place to place, but a lot more needs to be done in many areas. For example, with the extent of the cultural diversity of both providers and users of health services, every effort should now be made to ensure that assessment is done by a professional who has an understanding of the patient's culture. The authors state that systems are not required to be colour-blind, as this is not helpful. What is required is an acknowledgement of the disadvantages that people from ethnic minorities face and the implementation of measures to address these: denial is not the way forward.
The authors point out the fault lines in the assessment of dangerousness by psychiatrists and the tendency to be more cautious now, thereby leading to overprediction of dangerousness. They argue that this results in greater overprediction in Black people, which in turn is partly responsible for their overrepresentation in secure settings. The suggestion that psychiatry should be explicit about the limitations of making judgements regarding individual dangerousness is welcome, but this should not preclude offering an informed view on the available information and also on the interplay between mental disorder and dangerousness, where indicated. A move away from illness analysis to ‘real-life analysis’ is advocated, but this view needs more elucidation.
The authors suggest increasing resources to institutions run by Black mental health professionals that aim to provide alternatives to psychiatric hospitals. However, such facilities can at best serve as adjuncts, because many patients, whatever their racial background, need the type of care provided in mainstream psychiatric hospitals, and it is the provision of care in these hospitals that should reflect the diverse cultural and ethnic needs of their users.
The authors argue that appointing more professionals from ethnic minorities in the mental health services does not generally lead to improvement in service provision, because of constraints on those individuals. They note that people previously identified as radical become conservative on being appointed to higher positions. Although therefore questioning the drive to recruit increasing numbers of people from ethnic minorities, the authors also note the relatively small number of Black people in senior positions in various parts of the criminal justice system. Increasing these numbers should strengthen their influence on the changes required for a true multi-ethnic society. Perhaps a way of assuaging the main concern of the authors is for Black people appointed to senior positions to be made to sign a ‘Radicality Act’ just like the Official Secrets Act, to ensure that they remain radical after their appointment.
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