Remembering Blackwood, Martin and Watts

We all remember the name Orville Blackwood. He was a young, Jamaican-born British man with a diagnosis of schizophrenia. On 28 August 1991, Blackwood had his final seclusion review at Broadmoor Hospital. At the age of 31, almost immediately after being given intramuscular rapid tranquillisation under restraint, Orville Blackwood was dead.

Blackwood was the third in a sequence of young Black men of African–Caribbean origin to die inside Broadmoor’s seclusion rooms, following patients Michael Martin and Joseph Watts. An inquiry, chaired by Professor Herschel Prins, was established to investigate the circumstances of these deaths. There is a tendency in healthcare to blame an individual, perhaps even the patient. But the problem here was, in fact, the system.

The 1993 Prins report concluded that institutional bias against racial minorities contributed to the deaths. ¹ The phrase ‘Big, Black and Dangerous’ was used so frequently by witnesses, including clinical staff, to describe Blackwood and other patients that it became the report’s subtitle. A critical phrase, it seems, we have since forgotten.

The 1990s were a long time ago, so it would be easy to assume that things must be different now. However, although the Prins inquiry brought systemic racism in psychiatry to light, what has changed is not the stereotype itself but the attention given to it. The assumption that this longstanding stereotype is irrelevant to contemporary racial disparities is reflected in its absence from mainstream discussions on inequality. Take the UK’s proposed Mental Health Bill, introduced in 2024, which aims to reduce racial disparities by modernising the Mental Health Act 1983. Its well-meaning approach, focused on reducing detention rates overall, risks overlooking the racial biases that contribute to the disproportionate detention of people of colour. Challenging this assumption is where this article begins. I argue that the ‘Big, Black and Dangerous’ stereotype continues to shape inequalities in access, diagnosis and treatment in psychiatry, and that the idea it no longer matters is itself part of the problem.

At the back of our minds

What evidence is there that the ‘Big, Black and Dangerous’ stereotype persists at a subconscious level? Studies have demonstrated it. In a 1990 study titled ‘Are British psychiatrists racist?’, 139 British psychiatrists were presented with case vignettes describing psychotic patients of different races. The African–Caribbean cases were more likely to be judged as potentially violent and as more appropriate for criminal proceedings than the White cases. ^{Reference Lewis, Croft-Jeffreys and David2}

Although that 1990 study has since been criticised for its methodology, a similar 2007 UK study found that, among a racially diverse cohort of forensic psychiatrists, even Black and minority ethnic psychiatrists, like their White colleagues, were 2.8 times less likely to diagnose African–Caribbean patients accurately with personality disorders compared with White patients. ^{Reference Fernando3,Reference Mikton and Grounds4} Not even clinicians of colour, including myself, are insulated from this institutional racial bias, just as the Prins report observed.

Déjà vu: remembering Olaseni Lewis

One might have hoped that the deaths of Blackwood, Martin and Watts would have been sufficiently devastating to prompt a dismantling of this stereotype. Nonetheless, in the absence of targeted action, the ‘Big, Black and Dangerous’ narrative continues to be overlooked.

We know this because deaths of Black men at the intersection of the mental health and criminal justice systems have continued since the 1990s. One such case is that of Olaseni Lewis, a 23-year-old Black university graduate. Lewis began exhibiting uncharacteristically odd behaviour on 31 August 2010, and was admitted informally to a South London psychiatric ward. He was detained after becoming increasingly agitated, and police were then summoned and moved him to seclusion. Eleven officers were involved in his prolonged restraint, during which he became unconscious and suffered a cardiac arrest. ^{Reference Lynch5}

This recurrence is no coincidence. It exemplifies how deeply embedded the ‘Big, Black and Dangerous’ stereotype remains within mental health services, and how its legacy continues to shape the racial inequalities in psychiatric care today.

The legacy continues: modern-day racial inequalities

On the face of it, ‘Big, Black and Dangerous’ may appear justified by contemporary statistics on locked and secure mental health services, in which Black people have long been overrepresented. ⁶ For example, UK data from 2006 showed that Black patients were overrepresented eightfold in high-secure hospitals. That same year, in medium-secure hospitals in England and Wales, Black Caribbean patients were up to 15 times more likely to be detained than White patients. ^{Reference Leese, Thornicroft, Shaw, Thomas, Mohan and Harty7} Now, even when Black people in the UK are referred to mental health services, they are more likely to be referred via the criminal justice system than their White counterparts. ⁶

This pattern extends into general adult mental health services. Frequently cited in support of the Mental Health Bill is a familiar statistic: Black people are around four times more likely to be detained under the Mental Health Act compared with White people. While on the ward, they are also more likely to be subjected to restrictive practices. ⁶ Evidence linking psychiatric practice to the ‘Big, Black and Dangerous’ stereotype appears in early transcultural work by Suman Fernando, Maurice Lipsedge and Roland Littlewood. Since at least the 1980s, UK studies have found that Black psychiatric in-patients are disproportionally labelled as ‘dangerous’ without adequate objective evidence, and are overrepresented in compulsory detentions. ^{Reference Fernando3} In their book Aliens and Alienists (1982), Lipsedge and Littlewood highlighted studies showing how this stereotype influences risk assessments and decisions around coercive treatment. ^{Reference Littlewood and Lipsedge8}

More recent psychological research from 2017 identified a ‘formidability bias’, whereby young Black men are perceived as larger and more physically threatening than comparable White men, with these perceptions linked to greater support for the hypothetical use of force against Black crime suspects. ^{Reference Wilson, Hugenberg and Rule9} Nevertheless, studies of UK high-secure hospitals have found no difference in rates of current violence between Black and White patient groups. ^{Reference Leese, Thornicroft, Shaw, Thomas, Mohan and Harty7}

Blanket solutions

Perhaps the most telling sign that the ‘Big, Black and Dangerous’ stereotype is being overlooked is its absence from current discussions of racial inequality in mental health. Current reforms largely adopt universal approaches, such as the Mental Health Bill’s focus on reducing detention rates rather than addressing specific drivers. Similarly, the recent Patient and Carer Race Equality Framework risks falling short by focusing on downstream inequalities such as access, rather than offering any resources directly targeting the upstream institutional bias identified as early as the Prins inquiry.

This would not be the first time that policy interventions have struggled to achieve racial equality. Despite numerous initiatives, there remains limited evidence that existing policies have substantially reduced disparities. In 2005, for example, the UK government pledged to achieve racial equality in mental health care within 5 years through the programme Delivering Race Equality in Mental Health Care. However, the 5-year evaluation, including analyses by Melba Wilson, found little progress, citing the difficulty of achieving societal change through service-delivery reforms alone. Over 20 years on, the goal remains distant. This suggests that reliance on blanket solutions is insufficient. Without tackling the embedded stereotype within our mental health system, meaningful change is unlikely to follow.

Forget me not

Although the ‘Big, Black and Dangerous’ narrative has been long entrenched, and persistently reinforced, by the mental health system, the first step towards addressing this deeply embedded problem is simple: we must remember.

Psychiatry training would be a good place to start dismantling institutional bias. It is difficult to justify the exclusion of the history of racism in psychiatry from the Membership of the Royal College of Psychiatrists syllabus, particularly when other aspects of the history of psychiatry are taught and examined. If we are serious about erasing this stereotype, psychiatry training must not continue to ignore it.

Peer-led teaching on racism in psychiatry may help resident psychiatrists identify their own biases. This could be replicated across regional postgraduate core psychiatry courses, with sessions for resident psychiatrists to present to one another on topics such as the history of racism in psychiatry. Local academic programmes could also be targeted. Just as resident psychiatrists routinely present complex cases and journal clubs, presentations could occasionally centre on racial bias, encouraging discussion and reflection among psychiatrists of all grades and experience.

Despite the countless times I have completed information governance training, I have never been offered anti-bias training. However, as we have seen through the enduring legacy of a single stereotype, racial inequality is as critical as patient data handling. So why are we left to educate ourselves? Anti-bias training should be compulsory for psychiatrists. While the evidence base remains limited, preliminary studies involving doctors, nurses and physician associates suggest that brief online anti-bias education – including teaching on implicit bias, the history of racism in medicine and bias-mitigation strategies – can increase awareness regardless of baseline attitudes. ^{Reference Sabin, Guenther, Ornelas, Patterson, Andrilla and Morales10} In practice this could include e-learning modules within trust mandatory and statutory training, or webinars hosted by the Royal College of Psychiatrists.

To disentangle the ‘Big, Black and Dangerous’ stereotype from psychiatry, we must go further than remembrance. We must challenge ignorance of the history. And, once we recognise our biases, we must sit with them and talk about them. To put it bluntly, we must all do the work.