The imposition of restricted hospital orders: Potential effects of ethnic origin
Introduction
In 1999/2000, estimates derived from the Labour Force Survey indicated that 2% of the population aged 10 and over in England and Wales were of Black1 ethnic origin, 3% were of Asian origin, and 1% were of other non-White ethnic groups (Home Office, 2000). Despite this, in June 1999, Black people accounted for 12% of the male and 19% of the female prison population (Home Office, 2000). The observation that the Black population is overrepresented in prison populations was also observed by Coid et al. (2002).
A number of theories have been advanced to explain why Black people should be overrepresented in criminal populations. One is a higher level of criminality due to biases in other areas, which results in the Black population being disadvantaged in terms of employment and homelessness. Stevens and Willis (1979), however, showed that although inner-city areas had higher rates of crime, there was no evidence that crime was greater in areas where there was a larger Black or Asian population.
In England and Wales, the principal legislation governing the compulsory detention of those suffering from mental disorder is the Mental Health Act 1983. It has been shown that rates of detention of Black people under all sections of the Act are greater than those for the White population (Cope, 1990). Although Bebbington et al. (1994), in an audit of admissions in two health districts, found that ethnicity did not appear to be of principal importance in decisions to use the Mental Health Act, but there was a strong link between ethnicity and diagnosis. Thomas, Stone, Osborn, Thomas, and Fisher (1993) found that within Manchester, the rates of both admissions and, indeed, readmissions were greater among African Caribbeans compared with the Asian and European populations. A number of theories have been proposed to explain this. Pipe et al. (1991) argued that Black men are seen as being more threatening and disturbed, which may account to some degree for their overrepresentation. Cochrane (1977) studied admissions to nonsecure psychiatric beds and found that schizophrenia was diagnosed three times more frequently in Black than White people. Sharpley, Hutchinson, McKenzie, and Murray (2001) outlined the possible explanations of such an apparent excess of psychosis among the Black population as the result of biological, social, and psychological factors. A number of social theories have been proposed, many related to the links between run-down inner-city areas and high rates of psychiatric admissions, including stressful life events, overcrowding, higher crime levels, and lower social economic status (Sharpley et al., 2001). An explanation supported by Thomas et al. found that unemployment levels were significantly higher in the African Caribbean group studied, resulting in the authors arguing that the African Caribbean group was more socially disadvantaged than the other ethnic groups studied.
Forensic psychiatry represents one aspect of the interface between the criminal justice system and psychiatric services. Boast and Chesterman (1995) have shown that Black people made up a greater proportion of patients in secure psychiatric hospitals when compared with their numbers among the general public. In a study of admissions to one medium secure unit in England, Cope and Ndegwa (1991) found that Black people accounted for 38% of the sample. Part III of the Mental Health Act 1983 relates to the detention in hospital of those involved in criminal proceedings. According to a study by the National Association for the Care and Resettlement of Offenders (NACRO) (1990) this was used twice as often for Black defendants as for White. Coid et al. (2002), however, found that although research identifies that persons of African–Caribbean origin are more likely to be admitted to secure psychiatric facilities, there was a lower prevalence of psychiatric morbidity observed among Black prisoners.
In England and Wales, either a Crown court or magistrates court can make a hospital order, under which a mentally disordered offender may be detained in a hospital. This can be made only on conviction for an offence punishable by imprisonment and when certain statutory conditions are satisfied. A restriction order may be made by the Crown court, if it considers it necessary to make the order to protect the public from serious harm, having regard to the nature of the offence, the antecedents of the offender, and the probability of further offending. The restriction order prevents the offender from being discharged, granted leave, or transferred without the approval of the Home Secretary, although an offender patient may be discharged by the Mental Health Review Tribunal, an independent review body whose members are appointed by the Lord Chancellors department (Dell & Grounds, 1996). Street (1998) acknowledged that mentally disordered Black people being dealt with by the courts, are more likely than their White counterparts to be given a hospital order or a hospital order with restriction on discharge and then be sent to conditions of high-security psychiatric care due to the perception of Black people as being more dangerous.
For all the above reasons, it seems possible that there may be an overrepresentation of Black people among those committed to hospital following a conviction for a criminal offence and made subject to the most stringent form of statutory order. The aim of the present study was therefore to compare the characteristics of the Black and the non-Black population in a cohort of restricted patients admitted to and, subsequently, discharged from, one medium secure psychiatric unit, a health care facility admitting large numbers of mentally disordered offenders, in England. It was intended to identify any differences between the two groups in terms of criminological and other factors that might offer some possible explanation for the disproportionately high numbers of Black people subject to a restricted hospital order.
Section snippets
Method
A retrospective case note analysis was undertaken of all hospital records and clinical notes of restricted hospital order patients conditionally discharged from one large medium secure unit between 1987 and 2000. Details concerning previous criminal history were obtained from the Home Office Offender Index. Participants were assigned to two ethnic categories, namely, Black, which included all black African–Caribbean individuals and those of African and African–Caribbean origin, and non-Black,
Results
There were 55 people conditionally discharged from a restricted hospital order from the medium secure unit during the 13-year study period. In general, this group was similar in most of their characteristics with those admitted over the same period. Twenty eight (50.9%) were White, 22 (40%) Black, 4 (7.3%) Asian, and 1 (1.8%) of other ethnic origin.
The Black group consisted of 20 males (36.4% of the total sample) and 2 females (3.6%) compared with the non-Black group, which consisted of 29
Discussion
The current study has some limitations due to its specific focus on patients given restricted hospital orders, subsequently discharged from only one medium secure unit. The point of discharge was chosen as the focus for the study as a means of ensuring the quality and quantity of information required to allow meaningful analysis. It also allowed the inclusion of those patients where the restricted hospital order was imposed, but who were not admitted to the medium secure unit directly subject
Conclusion
For whatever reason, in England and Wales, Black people are disproportionately likely to come in to the care of mental health services, and in certain circumstances, be more likely to be made subject to a restricted hospital order. The findings from one medium secure unit presented here suggest that further research is required. The reasons for the differences observed and why the antecedents of the offender should be more important for the Black group when compared with the non-Black group are
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