Mental Health in a Multi-Ethnic Society

A Multidisciplinary Handbook

Dr Suman Fernando, Frank Keating, Dr Suman Fernando, Frank Keating

• Publisher: Routledge
• Year: 2008
• Print ISBN: 9780415414876
• eBook ISBN: 9781134120994
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This new edition of Mental Health in a Multi-Ethnic Society is an authoritative, comprehensive guide on issues around race, culture and mental health service provision. It has been updated to reflect the changes in the UK over the last ten years and features entirely new chapters by over twenty authors, expanding the range of topics by including issues of particular concern for women, family therapy, and mental health of refugees and asylum seekers.

Divided into four sections the book covers:

• issues around mental health service provision for black and minority ethnic (BME) communities including refugees and asylum seekers
• critical accounts of how these issues may be confronted, with examples of projects that attempt to do just that
• programs and innovative services that appear to meet some of the needs of BME communities
• a critical but constructive account of lessons to be drawn from earlier sections and discussion of the way ahead.

With chapters on training, service user involvement, policy development and service provision Mental Health in a Multi-Ethnic Society will appeal to academics, professionals, trainers and managers, as well as providing up-to-date information for a general readership.

Part 1
Current scene

Mental health is something we all aspire to, and the provision of services for people with mental health problems is undoubtedly an obligation of society. The preferred style in most of the industrially developed world is for care to be provided in the community on an informal (voluntary) basis, although hospital care including locked units, where people’s ordinary human rights are curtailed, is all too common. In such a situation, society is beset by problems of equity and fairness, especially evident with respect to issues around cultural diversity and ‘race’.

This part of the book sets the stage for the rest of the book. It provides a background to mental health service provision as it affects black and minority ethnic communities in British society by examining the socio-political-legal context in which services are provided, culturally determined differences in the understanding of health and illness, the nature of the inequalities that are all too evident, the special position of women and the history of training to bring about race equality.

Chapter 1
Meanings and realities

Suman Fernando

The discourse within mental health circles in Britain has changed considerably over the past fifteen years; ‘health’ is talked about instead of ‘illness’ and even ‘symptoms’, ‘service users’ instead of ‘patients’ and ‘interventions’ instead of ‘treatment’. Currently there is talk about ‘spirituality’ in mental health care (e.g. Cornah, 2006; Sperry, 2001; Swinton, 2001) and ‘recovery’ in place of ‘care’ (see Department of Health, 2001; Lester and Gask, 2006; Pitt et al., 2007). That is the talk. Yet in practice, mental health services in the statutory sector (within the National Health Service) are dominated by the traditional bio-medical approach characteristic of western psychiatry, whether in community care settings, outpatient clinics or inpatient units. Admittedly, though, this may not be the case in a few instances and in services in the voluntary sector, i.e. non-governmental organisations.

In this chapter I shall explore first the use of some terms within the race and culture discourse, such as ‘race’, racism, culture and ethnicity. Next I will discuss the diverse ways in which the concept ‘mental health’ is understood, and then go on to explore what mental health care is all about — or should be.

Terminology of ‘race’ and culture

The classification of human beings into ‘races’ based on certain visible physical characteristics, particularly skin colour, has a long history in Western Europe (see Dobzhansky, 1971; Molnar, 1983). Today the idea of a ‘racial type’ and ‘race’ (based on physical appearance) is no longer useful in human biology (J.S. Jones, 1981) and has been largely discredited — as discussed by me elsewhere as ‘myths and realities of race’ (Fernando, 2002: 19–25). Yet, ‘race’ as a social reality persists mainly because of racism — a doctrine or dogma based on a belief in ‘race’ that fashions or determines behaviour, ways of thinking, assumptions we make and so on (see Banton and Harwood, 1975; Husband, 1982). For practical purposes racism should be distinguished from race prejudice — a feeling or attitude of mind, expressed as ‘an antipathy based upon a faulty and inflexible generalisation’ (Allport, 1954: 9). As Wellman (1977) argues in Portraits of White Racism, once race prejudice is embedded within the structures of society, individual prejudice is no longer the problem — ‘prejudiced people are not the only racists’ (1977: 1). The notion of ‘institutional racism’ first appeared in a book on ‘Black Power’ by Stokely Carmichael and Charles Hamilton (1967). The Macpherson Report (Home Department, 1999), dealing with the failure of the London (Metropolitan) police to properly investigate a racist murder, opts for the following definition:

The collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour that amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping that disadvantages minority ethnic people.

(1999: 28)

Many of the racist stereotypes of black people originate in the era of colonialism and slavery. Their history and power in European culture have been tabulated and illustrated by Gilman (1985) and Pieterse (1992). The strength of stereotypes in a racist discourse was enunciated in Frantz Fanon’s Black Skin, White Masks (Fanon, 1952) and Edward Said’s Orientalism (Said, 1978). And, as Jean-Paul Sartre (1948) said of Jews in the past, black people often believe the stereotypes that others have of them — or, at least, behave as if they do, thereby sometimes helping to maintain their own oppression. However, it should be noted that racist images can change from time to time and from place to place, reflecting the changing face of racism. And instead of racism being openly applied in racial language it may be applied in cultural language or the language of religion. Thus, instead of stating — or implying — that ‘other races’ are inferior, possess some unsavoury characteristic or pose a threat to social cohesion, the reference is to ‘other’ cultures, religions, ethnic groups or kinds of people, thought of in the same way as ‘races’, that is groups that are unchanging and easily recognisable usually by physical appearance. Racism against Jews, namely anti-Semitism, is in fact hostility towards (what is perceived as) a racial group although defined in terms of religion; religious practice and belief do not come into it. More recently, especially since the attack on New York in September 2001, Islam (a religion) has been used to signify the racial ‘other’ in a similar way, with victimisation being justified on the grounds of preventing ‘terrorism’. This type of racism has been termed ‘Islamophobia’ (Casciani, 2004; Halliday, 1999; Seabrook, 2004). This shift is seen in the statistics for ‘stop and search’ by British police under the Terrorism Act (2000). It is well known that BME groups are much more likely than other groups to be subject to this police activity (see Chapter 3). The rate of being subject to stop and search for black (African and Caribbean) people increased by 30 per cent between 2001 and 2002, but the increase for (brown-skinned) Asian people was even higher at 41 per cent (R. Cowan, 2004; Metropolitan Police Authority, 2004). The ethnic disproportionality figures for stop and search in London between April and August 2007 were 2.1 for Asian:White and 1.6 for Black:White (Metropolitan Police Authority, 2007).

Mixed race

The historical issue of ‘race mixing’ has been a prominent part of the discourse of European racism. The idea that such ‘mixing’ would be a threat to the integrity of the ‘white race’ and lead to loss of white supremacy led to pejorative terms such as ‘miscegenation’ and theories of maladjustment and marginality of people who did not ‘belong’ to one ‘race’ or another (Furedi, 2001). The place of ‘mixed race’ as an ethnic identity is difficult to unravel but potentially important. The statistics on ‘mixed race’ derived from the census (2001b), based on a question about ‘culture’ (an example of the confusion between culture and ‘race’ noted below), were discussed in the Introduction. Although the concept of ‘mixed race’ has been criticised because its use reifies ‘race’ (Parker and Song, 2001) — in other words, we are all racially ‘mixed’ in a biological sense — as a social category, ‘mixed race’ seems here to stay (Smith, 2007). How it pans out depends very much on how society itself deals with ideas about ‘race’, nation and culture in the future. Research among British children by Suki Ali (2003) shows that the understanding of ‘race’, racism, culture and ethnicity in terms of how children build their identities may be complex and flexible. In her studies of children with multi-ethnic parentage in London and Kent:

Children of both black and white mothers, in all locations and across classes, identified themselves as ‘mixed-race’. Children of both black and white mothers also identified as black. None of the children from Malaysian, Polynesian, Chinese or Turkish backgrounds identified solely with that part of their heritage…. What seems to be most important is the way in which parents (mothers) communicate with children about their identities. In this process, location and parental history, and parental connections to ‘diaspora’ or an imagined ‘home’, play a crucial part for the negotiation of ethnic identification.

(Ali, 2003: 174, italics in original)

Culture and ethnicity

Traditionally (for example in anthropological literature) ‘culture’ refers to non-material aspects of everything that a person holds in common with other individuals forming a social group (such as child-rearing habits, family systems, and ethical values or attitudes common to a group), described by Leighton and Hughes as ‘shared patterns of belief, feeling and adaptation which people carry in their minds’ (1961: 447) — and in general pass on from generation to generation. But in today’s world, culture has a much looser meaning, as expounded in the book The Location of Culture by Homi Bhabha (1994).

In general, culture refers to ‘conceptual structures’ — a flexible system of values and worldviews that people live by, define their identities by and negotiate their lives by (Fernando, 2002) — a sort of road-map for living, relating to one another and so on. In a more practical sense, cultures are ‘systems of knowledge and practice that provide individuals with conceptual tools for self-understanding and rhetorical possibilities for self-preservation and social positioning’ (Kirmayer, 2006: 163). In other words, ‘culture’ is located in — emanates from — real lives of real people; it comes out of the struggles and connections with one another, the wishes and dreams of ordinary people against a background of heritage, what we inherit culturally, a sort of cultural DNA. So naturally there is a variety of experiences with greater or lesser degrees of similarity across cultures. And, no culture is static. ‘Cultural groups’ can be recognised by the degree to which individuals are similar, but we have to be careful not to stereotype.

In practice we tend to regard a variety of items as indicative of a person’s culture — markers of culture, although these too are variable. They include main language or mother tongue, religious affiliation (or nominal religion), background in terms of heritage, values, loyalties, certain practices (say about food), dress codes, kinship ties, ‘cultural’ habits such as marriage preferences, worldviews and so on.

Ethnicity is a subjective impression of how people see themselves. It is an ambiguous term in that one’s ethnicity may be different according to context and change from time to time. In practical shorthand, the term ‘ethnic’ is taken to mean (at least in the UK) a mixture of cultural background and racial designation as experienced by a person, a family or group of people — the significance of each (i.e. ‘culture’ and ‘race’) being variable, depending on context. If racism is felt strongly, people from various backgrounds and cultures may see themselves largely in racial terms (e.g. as ‘black people’) but also (or alternatively) identify themselves in ‘cultural’ terms of history, religion or parental birthplace (e.g. as ‘Muslims’ or ‘Caribbean’ or ‘Asian’). The current tendency in the UK is to refer to ‘black and minority ethnic communities’ or BME communities, leaving open the issue of what exactly an ethnic community comprises. But this means that recent immigrants, especially refugees and asylum seekers, often get left out of the BME category and may be called ‘migrants’ (as different from BME) — a category of exclusion in many parts of Europe.

Multicultural/multi-ethnic society

In the sense of the meaning of ‘culture’ that I have outlined, a multicultural society is one where there is a plurality of cultural forms and influences — a diversity of cultures. A multi-ethnic society is then a multicultural society that includes people seen as belonging to several ‘races’. In the UK, we have developed a form of ‘multiculturalism’ which goes back to 1966 when the then Home Secretary, Roy Jenkins, voiced the overall aim of social policy to promote integration of immigrants from non-western cultural backgrounds as ‘equal opportunity accompanied by cultural diversity in an atmosphere of mutual tolerance’ (Poulter, 1990: 2).

The idea being put about recently in Britain is that multiculturalism has led to ‘self-segregation’ and to an ‘isolationism’, especially among Muslims; the head of the Commission for Racial Equality, Trevor Phillips, has talked about ‘sleepwalking our way to segregation’ (Leppard, 2006: 2). However, research does not bear this out: Ludi Simpson (2004) found evidence in Britain of increasing dispersal of ethnic minority groups, even in Bradford, where the so-called ‘riots’ of 2001 were blamed on segregation of Muslim communities (see Independent Review Team, 2001), in spite of real barriers resulting from racism and activities of the extreme right, reviewed at the time in an eminent British newspaper (Observer, Editorial, 2001).

One reason, apart from obvious political agendas of right-wing groups, for this attack on British multiculturalism stems from the conflation of (or confusion between) ‘race’ and ‘culture’, coupled with the use of the ambiguous term ethnicity. National statistics about ethnic groups are interpreted both as differences in ‘culture’ and differences in ‘race’ — you take your pick. Racists (whether consciously so or not) have a field day, and others get drawn in, perhaps in the way Amartya Sen (2006) records in his recent book Identity and Violence. When people are identified in ‘ethnic’ terms (both ‘cultural’ and ‘racial’), we tend to impose ‘culture’ on people because of the way they look (‘racially’) instead of allowing people to find their own position in the stream of changing and varied cultural forms. Then, people resent this feeling of being assigned to having just one overarching ‘culture’ (one’s ethnic group), essentially given this because of the way one looks (racially). ‘Multiculturalism’ gets blamed instead of the real culprit, racism expressed through cultural language.

Another problem that arises when ‘culture’ and ‘race’ are conflated is that ‘culture’, and hence multiculturalism, is seen as concerning non-white people alone. So, cultural diversity remains a minority issue and multicultural society a place where minority (i.e. ‘Black and Asian’) issues are given primacy. To complicate this discourse, racism undermines multiculturalism by introducing the idea (not necessarily expressed openly) that cultures are on a hierarchy of sophistication, some being less ‘developed’ than others, and so feeding on the negative aspects of discourse in the international scene where ‘under-developed’ or ‘developing’ countries (and their ‘cultures’) are seen as ‘primitive’ and needing to be changed for the better. So, effective multiculturalism must have an anti-racist dimension or else there would not be equity within the (multicultural) society. But a multicultural society must include the opportunity for white people to belong, to have a ‘culture’ or, more correctly, several ‘cultures’.

Conclusions

The concepts ‘race’, culture and ethnicity tend to get mixed up in our discourse and in our thinking, but they have different emphases. Although race is a scientific myth, it persists as a social entity for historical, social and psychological reasons — in fact for all the reasons that result in racism. And skin colour remains the most popular basis for distinguishing one race from another in a British — possibly West European — context. When a group of people are perceived as belonging to a racial group, the assumption is of a common ancestry with implication of biological similarity. So when a society is referred to as being ‘multiracial’, that means it contains people whose ancestries vary; but, more importantly, that these ancestries are related to their heritage, their biological makeup — their ‘blood’.

What is mental health?

Mental health is a nebulous concept at the best of times. In a broad sense it is ‘a rubric, a label which covers different perspectives and concerns such as the absence of incapacitating symptoms, integration of psychological functioning, effective conduct of personal and social life, feelings of ethical and spiritual well-being, and so on’ (Kakar, 1984: 3). How this concept is best interpreted in the provision of mental health services in a multicultural context is complicated. Clearly we need to look carefully at differences in the way mental health is seen in the diverse (cultural) traditions that comprise British society — in broad terms, Asian, African, Caribbean, and European. But there are important reservations to this approach. Similarities (between cultural traditions) should never be under-estimated and generalisations (about cultural traditions) have dangers: they may be taken up as stereotypes of people who are seen as ‘belonging’ to one or other cultural group because of the way they ‘look’; or be used to reduce a specified culture to one or two basic tenets — in most instances misleading if not downright erroneous. Notwithstanding these problems, I do not see any other way of exploring cultural diversity in this instance except by comparisons between ‘western’ and ‘eastern’. However, by doing so, I am not implying that east and west are any more than traditions from the past — current states of mind rather than geographical regions (Kakar, 1984).

	Western tradition	Eastern tradition
Mind and body	Distinct entities	Indivisible whole
Analysis	Reductionist	Holistic
Tools for study	Objective	Subjecti...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• List of illustrations
• Notes on contributors
• Acknowledgements
• Introduction
• PART 1 Current scene
• PART 2 Confronting issues
• PART 3 Making it happen
• PART 4 Lessons for the future
• References