In some metropolitan circles, young black men are seen as cool. But a sizeable proportion of the white population fears them because they are so often portrayed as criminal, socially irresponsible and violent. White fear is also fuelled by the perception that they are unstable and prone to mental illness. But many black people are similarly fearful - not only of racism in general, but of what they regard as racial discrimination in the operation of Britain's mental health system.
These circles of fear have helped to prevent much-needed change in our mental health professions and institutions and today, in Birmingham, a small step is being taken to try to undo this paralysis. A meeting of black service users, carers and local mental health agencies is being held as part of the Sainsbury Centre for Mental Health's Breaking the Circles of Fear project. Two similar meetings have already taken place in London.
Frank Keating, senior research fellow for the project, explains that it is trying to explore impediments to change and investigate models that really work for black communities. He says evidence of discrimination - intended or unintended - has been available for 15 years and he thinks it is time for everybody involved in mental health to move on.
This evidence shows that people from African and African-Caribbean communities are between three and 13 times more likely than others to be admitted to hospital under the Mental Health Act. The prevalence of mental illness among black prisoners is three times higher than among their white counterparts. Black patients are given higher doses of neuroleptic drugs, are more likely to receive electro-convulsive therapy or be subject to restraint, and are less likely to be offered psychotherapy or other alternative treatments.
Through local meetings, like today's, and a broader programme of evidence gathering and consultation with black service users and their families - as well as with black agencies and other providers of mental health services - the centre aims to present some practical proposals to policymakers.
Oneal Thomas, who manages the Antenna Outreach Service for young black people in Tottenham, north London, reinforces the "circles of fear" message. He says the service, which is a leading partner in the project's work, is very aware that pressures caused by racism contribute to mental health problems. "For example, you hardly ever hear anything positive about black people; it's always about problems, so we all get locked into the disadvantaged communities debate and no one feels able to move on."
The general distress felt in black communities seems to affect young men more than women, Thomas says. "The mix of perceptions by white people about crime, violence and distress tends to focus on young men. Consequently, we find that they're less likely to engage with mental health services. So we view as our main task the reaching out to young people who are in need, and at risk, and who you know may have a major breakdown if we don't work with them as soon as possible.
"Our staff, who are African-Caribbean, are able to take a holistic view and so be able to look at people's aspirations and situations, rather than concentrate solely on their mental health problems."
But does this mean that change can only be effected by black mental health agencies? John Cox, president of the Royal College of Psychiatrists, accepts that many people from ethnic communities have a negative perception of mental health services. "That's a harsh reality, and there is obviously a double stigma in having a mental disorder and being from a minority ethnic community," he says. "This results in a tendency to report very late to mental health services, and this is perhaps one reason why we see the treatments we do."
Cox, who is directly involved in the Sainsbury project, accepts a need for psychiatrists to gain more understanding of customs and mores. "Training in cultural competence is one of our key aims: we'll be setting up an ethnic minorities committee in the college to help further this, and we're mounting a campaign to combat racial stigma in order to influence the, often defensive, attitudes of mental health services."
Cutting across these institutional and organisational issues is another, potentially powerful, intervention by researchers and psychiatrists. People from black communities are much more likely than white people to be diagnosed as having schizophrenia. But according to Kwame McKenzie, a north London consultant psychiatrist and honorary lecturer at the Institute of Psychiatry, the illness among black people may be very different.
What is the evidence for this? In essence, white people diagnosed with schizophrenia are several times more likely than their black counterparts to have an identifiable organic problem. There is no difference in brain structure among black people with the diagnosis, compared with a control group, and substantially fewer black people than white suffer from the form of long-term, persistent symptoms with which mental health services are familiar. But black people are more likely than whites to be regarded as having psychotic symptoms. Crises are more likely to be episodic and the prognosis is far better than for white people.
McKenzie says: "We've pretty well nailed down the fact that the risk factors for white and African-Caribbean people are very different, especially the life events and situations they have to face."
This undermines the whole idea of what we understand as schizo- phrenia in the African-Caribbean community, McKenzie maintains, and therefore the diagnosis of the illness itself becomes unstable. Startling as this may appear, debate about misdiagnosis of black people has been going on for several years. McKenzie believes that: "We need to look more closely at symptoms, such as hallucinations, depression, delusions, low motivation or manic symptoms, for example, and gain a broader understanding of the individual."
By doing this, he says, professionals can prescribe medication for particular symptoms and decide on other interventions, such as cognitive behavioural therapy, with the patient's agreement. This is not just theory, as McKenzie has been involved with treatment regimes based on this approach. "For example we found that low doses of anti-psychotics for a short period, and mood stabilisers to help a person get past an episode of manic or depressive disorder, allied to cognitive behavioural therapy which embraced the issues which led to the episode, have worked very well," he says.
This "dimensional", rather than "categorical", approach to schizophrenia - which appears to be gaining ground among professionals - may offer an effective clinical partner to culturally appropriate services. And today's meeting, which is hosted by Servol, another predominantly black mental health outreach charity in Birmingham, combines these themes with the practical experiences of black users and carers.
Hopes are high that the project will help change mainstream services. Not before time. Carl Douglas, who runs the National Schizophrenia Fellowship's African Caribbean development service in Birmingham, says: "Black people keep asking us what's happened to all the previous studies, and what's the point of them because nothing ever improves."
The Sainsbury project can be contacted through David Robertson on 020-7403 8790