Cultural Diversity, Mental Health and Psychiatry

The Struggle Against Racism

Dr Suman Fernando, Suman Fernando

• Publisher: Routledge
• Year: 2004
• Print ISBN:
  9781583912522
• eBook ISBN:
  9781135452704
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

'Black and minority ethnic communities lack confidence in mental health services', according to the National Service Framework for Mental Health published by the Department of Health in 1999.

Cultural Diversity, Mental Health and Psychiatry examines how and why this situation has come about, and makes specific practical, often surprising, suggestions for changing the status quo.

In his latest and most critical analysis, Suman Fernando reflects on the current situation in light of his own personal experience, academic research and anecdotal reports. He weaves together themes of immense importance for the future of psychiatry and mental health services in a multi-cultural setting, exploring:

* the nature of racism and its permeation into mental health services
* the inside story of the struggle against racism in statutory and voluntary sectors of the mental health system
* the history of psychiatry and the role of spirituality, holistic thinking, psychotherapy and Asian traditions of medicine.

Trainees, practitioners, and managers of mental health services will profit from the practical application of Fernando's latest ideas, and students and academics will benefit from his theoretical guidance.

Part I

Background

Chapter 1

Racism and cultural diversity

Racism exists in many societies in many different guises: as anti-Semitism in Europe, in the caste systems in India, within some aspects of Zionism in Palestine, etc. Even the conflict between people identified as ‘Catholic’ and ‘Protestant’ communities in Ireland is essentially based on the perception of people in racial terms as ‘born’ Catholics or Protestants. What Barzun (1965) calls ‘race-thinking’ appears to underpin many different conflicts today that are designated as ‘ethnic conflicts’. But racism based on skin colour is the type of racism that predominates today in western Europe and North America.

The word ‘culture’, traditionally applied to an individual, usually refers to a mixture of behaviour and cognition arising from ‘shared patterns of belief, feeling and adaptation that people carry in their minds’ (Leighton and Hughes 1961: 447). The allusion to family culture or the culture of whole communities extends the meaning of the word further. Therefore, referring to a multiplicity of cultures (say in a multicultural society) implies cultural differences between groups of people – communities with different backgrounds, traditions and world views. Over recent years there has been an outpouring of literature on the topic of ‘culture’ and cultural studies (see bhabha 1994; Said 1994; Eagleton 2000). The understanding of the term ‘culture’ has changed. Culture is no longer seen as a closed system that can be defined very clearly, nor something that is composed of traditional beliefs and practices that are passed on from generation to generation, but as something living, dynamic and changing – a flexible system of values and world views that people live by and create and re-create continuously. It is a system by which people define their identities and negotiate their lives. So, understanding culture, training in cultural understanding or learning about cultures other than one’s own, is about seeking an awareness of group norms collectively being created in the here-and-now in a context of the here-and-now.

Since ‘ethnicity’ is a popular concept for discussions about the multicultural and multi-racial nature of society, some comments on the term may be helpful. ‘The term ethnicity acknowledges the place of history, language and culture in the construction of subjectivity and identity, as well as the fact that all discourse is placed, positioned, situated, and all knowledge is contextual’ (Hall 1992: 257). In practical shorthand, the term ‘ethnic’ is taken to mean (at least in Britain) a mixture of cultural background and racial designation, the significance of each being variable. (It was, and still is, used differently on mainland Europe.) It is essentially about self-perception – how people see themselves – that takes on board the diversity of subjective positions, experience and histories of people. From a sociological point of view (e.g. Hall 1992; Malik 1996; Cohen 1999), the contemporary situation in Britain is seen as a shift into the construction of ‘new ethnic identities’ (Hall 1992: 256), new British ethnicities composed of people who see themselves (and are perceived) as adhering to ethnic groups that are different to the majority ‘white’ population. Stuart Hall (1992) sees this shift as a ‘change from a struggle over the relations of representation to a politics of representation itself’ (1992: 253). While at one time the term ‘black was coined as a way of referencing the common experience of racism and marginalisation in Britain’, today ethnicity is ‘predicated on difference and diversity’ (1992: 258). It should be noted that some writers have objected to this shift as deflecting attention away from ‘broad structural processes including racism’ in discussions about problems in health research and service provision (Stubbs 1993: 40). The point that needs grasping is that the importance of racism has not diminished. But instead of being a unitary concept that per se defines all problems, the central issue of race is ‘constantly crossed and recrossed by the categories of class, of gender and ethnicity’ (Hall 1992: 255).

This chapter considers very briefly the history of a black presence in the UK and other European countries. Then, it discusses the nature of racism, mainly in relation to the UK but touching on the European scene in general. The issues around multiculturalism, again mainly in relation to the British situation, will lead on to a consideration of ethnic issues in the mental health field. These refer mainly to black people being excessively diagnosed as ‘schizophrenic’, over-represented among people who are ‘sectioned’ (involuntarily committed to hospital) and apprehended in excessive numbers by the police as ‘mentally ill’, not referred for psychotherapy, and so on. All these issues have been known for over twenty years and commented upon extensively (see Fernando 2002), and so they are not described here in detail. A significant development in the 1980s and 1990s was the arrival on the mental health scene of services that aimed to provide specific services for black and other minority ethnic groups – ‘ethnic-specific services’. I make some comments about these services, describing a few in some detail. Finally, I discuss issues around race and culture in psychiatric research and end by making some general conclusions.

Ethnic minorities in Europe

There are isolated reports of black people in Britain during Roman times (Fryer 1984) but black communities as such were not evident in Britain until about the mid-eighteenth century. Initially, these communities were formed of African slaves brought back from the West Indies as servants, later joined by Asian servants brought back from India by returning nabobs – white people from Britain who made fortunes in India (Baron 2001). Later, African and Asian seamen employed in British ships settled in various ports. Thus, the most long-standing British communities identifiable today as ‘black’ or ‘Asian’ are descendents of African and Asian seamen who settled locally, traders, and escaped or freed slaves; they are located in or near formerly active seaports such as London and Liverpool in England, and Cardiff in Wales. However, the descendants of black Caribbean, African and Asian migrants of the 1950s and 1960s and their families now form most of Britain’s settled black communities. As a result of increasingly stringent controls on immigration into Britain applied from the mid-1970s onwards, recent arrivals who may be included within the designation of ‘black’ or ‘Asian’ are nearly all refugees (or people seeking asylum) and families of British residents who are allowed in usually after intensive vetting to establish that they are not ‘economic migrants’. On the whole, settled black and Asian British communities have spread from their original areas of settlement in cities to the suburbs and, in the case of middle-class and business people, to rural areas of Britain. Although refugees and asylum seekers have tended to settle in London, a policy of dispersal was instituted in 2000 to send new arrivals to various parts of the UK (Home Office 1998), a policy that led to serious suffering (Audit Commission 2000). Thus, sizeable black communities are now present in several cities including, for example, Glasgow, Leeds and Newcastle.

It is difficult to estimate the numbers of black people in Europe since most European countries do not collect figures on the ethnic breakdown of their populations. The European Union (EU) comprises fifteen countries at the time of writing, in 2002. Melotti (1997) calculates that 11.5 million residents of these countries are immigrants from outside the EU, 90 per cent of them (about 10.3 million) coming from industrially underdeveloped countries. Germany, France and the UK, in that order, rank highest for these non-European immigrants. However, these figures do not address the fact that a large number of black and Asian people living in the EU today are citizens of the countries in which they reside. In 1995, as part of my involvement in an informal group of workers in the mental health field (called ‘The Platform on Mental Health’), I collected information on ethnic minorities through contacts in various European locations. The figures (which have not been previously published) indicated that the number of ‘black Europeans’ numbered over 12 million in 1995 (Table 1.1). The numbers have obviously gone up since then and so today there are more black Europeans than there are white Swedes or Belgians.

The extent to which black Europeans are socially excluded and suffer from other forms of discrimination must vary from place to place. The Institute of Race Relations Race Audit Project, Statewatch (website: http://www.statewatch.org), that documents overt racism based on press cuttings and other information, is seldom short of reports of racial attacks on black people in nearly all European countries. Its January 2002 issue reports that racist and anti-Semitic violence in France ‘is on the increase, reaching its highest level since 1990’ (Institute of Race Relations 2002a: 7). School children seem particularly at risk of being attacked in Brandenburg in Germany (Institute of Race Relations 2002b: 11). Notwithstanding these (and other) signs of overt racism, it should be noted that all European countries, like Britain, have traditions of liberalism and resistance against persecution of people on racial grounds, and the EU has set its face against overt personal racism, for example by proposing that the lowest maximum penalty for incitement to racial violence or hatred should be two years imprisonment in all EU countries (European Union Institutions 2001), although it has so far taken no action on institutional racism.

Table 1.1 Ethnic minorities, including refugees and asylum seekers, in some European countries, approximate figures in 1995

Nature of racism

The era of colonialism and the Atlantic slave trade was the time when long-standing prejudices based on concepts of ‘race’ – especially skin-colour race – became integrated as racism into Euro-American culture, including the culture of psychiatry and psychology (Fernando 1988). In his analysis of the connection between racism and colonialism, Frantz Fanon (1967) has shown very clearly how ‘vulgar racism in its biological form’ (1967: 35), corresponding to a period of crude exploitation, changed into ‘cultural racism’ – ‘a more sophisticated form [of racism] in which the object is no longer the physiology of the individual but the cultural style of a people’ (McCulloch 1983: 120). This cultural racism, deeply embedded in European culture, is represented in western social and political systems as institutional racism of modern times. Today institutional racism and racial prejudice at a personal level exist together interacting with each other and affecting society in many different ways. However, since various meanings have been attributed over the years to the phenomenon of racism there is now a ‘crisis of meaning’ for the concept. As Omi and Winant (1994) state ‘Today, the absence of a clear “common sense” understanding of what racism means has become a significant obstacle to efforts aimed at challenging it’ (1994: 70).

Innumerable theories of racism have been put forward and descriptions of its effects abound. In his book, Racist Culture, Goldberg (1993) argues against treating racism as a homogenous phenomenon:

It follows that there may be different racisms in the same place at different times; or different racisms in various different places at the same time; or, again, different racist expressions – different that is, in the conditions of their expression, their forms of expression, the objects of their expression, and their effects – among different people at the same space-time conjuncture.

(1993: 91)

Thus, racism during American slavery differs from post-slavery segregationism and each from current expressions of racism in the United States (US). Racism in South Africa during the times of apartheid differs from that expressed through inherent economic inequalities in the post-apartheid era. Nineteenth-century British racism in the colonies differs from current manifestations of racism in the UK. Yet some generalisation of the concept (of racism) is possible – hence the justification for its use: ‘Concepts that are articulated resonate beyond the sites in which they were created’ (Goldberg and Essed 2002: 3). Racism does not just exist as an abstract concept; its importance lies in its relevance to social relations between people. While racism cannot be adequately explained in abstraction from social relations nor can it be explained by reducing it to social relations (Hall 1980).

Essed (1990) has developed the concept of ‘everyday racism’ that is very much about the personal experience of racism in the course of day-to-day interactions between people. The people who exhibit racism are not necessarily overtly (racially) prejudiced, although if one examined their attitudes in some depth racist attitudes may be uncovered. Their unwitting racism may be implemented through ways of behaving and socialising. But if this approach is taken further, racism may be manifested in social and political systems because people unwittingly collude in it, possibly they gain from doing so. Wellman (1977) argues in Portraits of White Racism, that once racial 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 idea of ‘institutional racism’ first appeared in a book by Carmichael and Hamilton (1997), Black Power. The Politics of Liberation in America. An inquiry into police failure in London to investigate the murder of a black teenager (Home Department 1999) defines institutional racism in terms of its practical effects – the ‘collective failure of an organisation to provide an appropriate and professional service’ (1999: 28). The problem, however, with this concept is that it seems to exclude the personal impact of racism on the individual and may appear to take responsibility for it away from the individual. However, recognising the main problem of racism as ‘institutional’ does not abrogate personal responsibility for racism. Anyone involved in a system that is institutionally racist is accountable, liable and blameable for their actions with special responsibility falling on those at the top of any system that is racist.

Modern racism

The lack of precision in defining racism results in much argument about its nature in the world of today – to the extent of questioning its very existence as a problem. Recently, when asked about the fact that only two of the eleven players chosen for its (cricket) test team were black – although 98 per cent of the population were black – the vice-chairman of Zimbabwe Cricket Union, while agreeing that black participation in the game was poor, said ‘I don’t like the word racism. It’s unfair. I wish it would go away’ (Meldrum 2001). Omi and Winant (1994) argue that a part of the problem arises from racism being seen as either an ideological phenomenon (with beliefs, attitudes, doctrines and discourse) that result in unequal and unjust practices, or as a structural phenomenon (with economic stratification, residential segregation, and institutional forms of inequality) that then gives rise to ideologies of privilege. They argue that ‘ideological beliefs have structural consequences and social structures give rise to beliefs’, so that racial ideology and (racist) social structure ‘mutually shape the nature of racism in a complex, dialectical and overdetermined manner’ (1994: 74–5). In fact, an inextricable linkage existed even in the development of the overtly racist plantation slavery of the US – the linkages between racism on the one hand, and on the other, shortage of cheap labour, the elaboration of juridical and property rights, and attitudes of racial superiority (Hall 1980).

Thus, ideological racism gets articulated through changing structural forms, and structural racism gets connected with changing ideologies. In such an open, flexible system, manifestations and locations of racism change constantly, especially in the face of opposition. Racism that was once openly applied in racial language is now 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 of 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. In recent times ‘alien cultures’ have been seen as a danger to British society, for example by Margaret Thatcher in 1978 when she talked of Britain being ‘swamped by people with a different culture’ (Fitzpatrick 1990: 249). And even more recently, especially since the attack on New York in September 2001, Islam (a religion) is being used in similar racial idiom, with victimisation being justified on the grounds of preventing ‘terrorism’.

One could visualise racism as an influence that permeates through a system hitching on to anything suitable for its purposes – any ideology, any discrimination, any facet of social functioning, any system of care, any educational enterprise, any construction of knowledge, etc. Racism then gets expressed through ideas of liberalism or democracy, culture or religion, conservatism or totalitarianism, gender differentiation, health care, psychological theories, medical systems, etc. So, in British society, racism – or perhaps racisms – takes, or take, diverse forms. The ‘everyday racism’ described by Essed (1990) merges into racial harassment and racial attacks which are still rife in many parts of the UK and on the European continent. Readers should see Virdee (1997) for a general survey, Collins (2001) on harassment of health service staff, Commission for Racial Equality (1987) for analysis of racial attacks in the UK, Carf (1997) for the death toll from racism in Europe, and Bjorgo (1997) for a survey of racism in Scandinavia. Although it is true to say that overt racial discrimination at a personal level – street racism – has declined over the past ten years in Britain (although this may not be the case in other European countries) it is still experienced in varying degrees by many black people in their everyday interactions with others. But it is the racism implemented through British institutional processes – institutional racism – that is proving most difficult to address.

Racism in the National Health Service was documented as long ago as 1983 (Commission for Racial Equality 1983) and studied in some depth (Anwar and Ali 1987). At that time, racism was approached mainly as personal prejudice but a recent book edited by Naz Coker (2001) points to the entrenched nature of institutional racism in the field of medicine. In this publication, Aneez Esmail (2001) points out how difficult it has been to research issues of racial discrimination in the admission of students to medical schools – not least because of political pressures aimed at preventing information on research getting into the public domain; Paramjit Gill (2001) describes the problems faced by black and Asian general practitioners because of racism; and Lyndsey Unwin (2001) outlines the complex ways in which institutional racism affects career progression in the National Health Service. A survey by...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Dedication
• Contents
• Figure, Tables and Boxes
• Acknowledgements
• Introduction
• PART I Background
• PART II Underlying themes
• PART III Changing practice
• References
• Index