Examining the ways in which institutions enact structural racism has always been a moral imperative.
Following the murder of George Floyd, and the subsequent worldwide Black Lives Matters actions, there is renewed political impetus to do so.
The time to act is now. Not just on police brutality, but also on institutional racism - which exists in health care just as it does elsewhere.
Medact’s new report False Positives examines the Prevent policy, part of the UK government’s counter-terrorism strategy.
The report challenges healthcare professionals to examine our own practices and our own complicity with a programme that the report describes as discriminatory against certain ethnic and religious minorities, stigmatising of people with mental illness and often harmful for those who are referred.
Medact’s key findings included:
- The scientific basis of claims that Prevent can detect people vulnerable to ‘radicalisation’ who might then progress onto committing acts of political violence is thin, weak and often hidden
- Furthermore, the evidence base that state interventions can deter such people from engaging in political violence is just as weak
- British Asians were four times more likely than non-Asians to be referred to Prevent by healthcare organisations
- Muslim people were eight times more likely than non-Muslims to be referred to Prevent by healthcare organisations
- People with mental health problems are over-represented in Prevent referrals from healthcare organisations - yet this may be the outcome of stigma too. The evidence for the government’s claim that people with mental health conditions are more likely to be drawn into terrorism is also far from robust.
Where does that discrimination come from? As previous research has pointed out, the problem is not so much that Prevent forces us all to be racist.
Sure, Prevent does focus attention on ethnic and religious minorities, even as it ostentatiously points out that attending a mosque is not a sign of radicalisation.
The ‘We’re not racist. Honest, guv’ line is somewhat belied by a guide produced by National Counter-Terrorism Police, and cited in Medact’s report, which warns that someone who ‘promotes the view that Muslims are persecuted in the UK by the government and media’ or voices ‘concern for “oppressed Muslims” in other countries’ could be a member of the Islamist group Al Muhajiroun.
But the bigger problem is that racial and religious biases exist in society – in all of us – and Prevent provides a framework to operationalise those biases. Moreover, it does so in a way that criminalises the people we refer.
This is the really toxic aspect of Prevent. We may well think we are doing a patient a favour by referring them into Prevent.
We may believe that we are catching the mentally unwell person at a point when they are vulnerable to being radicalised and then referring them into a programme in which they will be safeguarded and supported along a pathway away from violence and harm to self and society.
But this report demonstrates not just that there is scant evidence to suggest that such a pathway exists or that Prevent and Channel will help people along it.
When you refer a patient to Prevent, you refer them to a programme that operates on a logic of securitisation rather than care, in which they are seen as a potential terrorist in the “pre-criminal space”, rather than a person in need of compassionate assessment and treatment.
The report uses case histories to document the ways in which Prevent referrals can actively harm the people referred. Referrals erode trust and damage the therapeutic relationship between the patient and the referrer.
They cause additional stress and can trigger de novo mental illness and/or deterioration in pre-existing mental illness, both for the patient and his/her family.
In one case, a psychiatrist reflects that a Prevent referral damaged the therapeutic relationship between a BAME Muslim patient with schizophrenia and the medical professionals treating him, almost certainly setting back the man’s recovery.
The additional stress and erosion of trust then contribute to a negatively reinforcing cycle in which patients and families decline further offers of care and support, not just from healthcare organisations but also from other state educational and welfare institutions.
Therefore, already marginalised groups end up even more marginalised, with knock-on effects on the development and well-being of individuals.
So, what should healthcare professionals do? Of course, I agree that we should support Medact’s proposals, outlined in the final chapter of the report.
Most importantly, the Prevent programme should be stopped and efforts should be made to rebuild trust with targeted communities.
These are policy proposals for government, and we can lend our weight to them by calling on our own political representatives, unions and professional associations to support them.
But we should also examine our own individual clinical practice.
What is it that we are really saying about a patient when we consider referring them to Prevent?
If we consider them to be vulnerable to radicalisation, posing a risk that warrants referral to Prevent, we need to ask: Vulnerable in what way? What do we mean by radicalisation? What evidence do have of vulnerability, radicalisation or risk? Then we can ask how best to manage the vulnerability and risk.
Do we need a better psychological formulation, do we need to refer to adult safeguarding, or if there is an actual imminent risk of violence, then do we simply need to directly call the police?
Prevent encourages us not to ask these questions, not to think too deeply. Prevent training explicitly asks us to follow our “gut instinct”. But being anti-racist means doing the exact opposite.
Always examine where your instinct is taking you. Always be wary of the ways ethnic, religious and racial biases are influencing your thoughts, judgements and actions.
If we do not submit ourselves and our practice to deep self-reflection, then we run the risk of being complicit in the reinforcement and reproduction of institutional racism.
By ‘we’ I don’t just mean racists. I mean you and I mean me.
Piyush Pushkar is a CT3 in Psychiatry based in Manchester.