These new services were to have been fully in place by June 1996. Yet in 1997 as Raised Voices
showed, black people were still widely questioning the ignorance of the medical profession over
ethnicity and culture, and their continued failure to offer sufficient access to psychotherapy and
counselling.

What more can be done?

More discussion and engagement with black patients encouraging the particular
perspectives they bring could point the way to more appropriate service deliveries. This
needs to be achieved on a formal policy level, and at the level of individual reaction
between user and professional (Raised Voices p9).

III. SCHIZOPHRENIA AND BLACK ALTERNATIVES TO INSTITUTIONAL CARE

Fernando points out that the proof of the pudding is in the eating. Why is it that when the West
has all the treatments available, hospitalisations, neuroleptic drugs, mental health services, the
prognosis of schizophrenia is worse than in African/ Asian societies, or more traditional, rural
societies? ([1991] ch5). Warner [1994] also questions the prognosis of schizophrenia in the West.
We have already seen through Warner's eyes that Bleuer's system of community care for
schizophrenics had a better recovery rate for first episode schizophrenia (pp 9–11).

Bleuer's concept of social and economic support is close to traditional African and Asian
societies, who look after the mentally ill through the use of the extended family. The impact of
mental illness is less on the extended family than it is on the nuclear family. The episodes of
schizophrenia in these societies are comparatively brief.

These findings are undervalued in Western psychiatry because psychotic symptoms lasting less
than six months are not seen as 'real' schizophrenia (DSM III). In other words, if success rates are
apparently better elsewhere, then the patients were not 'really' mentally ill.

In rural societies mental illness is less stigmatising than it is in the West provided that you are
cared for by your extended family. There is more emphasis on work, and being a useful and
valued member of the community. Far fewer are hospitalised or put on drugs. Traditional
healing systems incorporate herbal remedies, dance and trance ceremonies, and spiritual
communications. In some societies, the mentally ill are seen as magicians, because they appear
'more in touch' with the spiritual world (Warner [1994], Fernando [1991]).

In the West, by stark contrast, the legacy of schizophrenia is stigmatisation, unemployment,
rejection by family and community. Negative press coverage has led to the picture of the typical
schizophrenic as a highly dangerous person. The lack of sufficient funding for care in the
community by many local authorities leads to the inevitable conclusion that the community
doesn't really care.

However, the extended family model has been used successfully in the UK in innovative black
alternatives to institutional care. The blueprint for this system is the Harambee Core and Cluster
Mental Health Project in Birmingham set up in 1985. ('Harambee' is the Swahili word for 'Lets
work together'.) The project was set up to address the failure of statutory and voluntary services
to provide credible after care facilities to young black mental health users discharged from
hospitals straight onto the streets.

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