This essay will analyse how issues of ‘race’ and culture are pertinent to mental health problems and to service responses to minority communities. However, other risk or causal factors will be considered which are essential in fully understanding diagnosis, access to services and outcomes of mental health issues including poverty, racism and violence against women. It appears that a combination of cultural, structural and individualist factors are linked to mental health issues and it will be highlight why an over focus on ‘race’ and culture (without considering other factors) can be dangerous.
Although individual factors will not be discussed in this essay, their importance must be emphasised. Personal elements intersect with other factors (structural and cultural) contributing to mental health problems. Individual factors on their own therefore are not enough but need to be considered in combination with cultural and structural factors. This can be linked to Thompsons PCS Model which looks at Personal, Cultural and Structural issues in terms of anti oppressive practice (Thompson, 1997).
It cannot be ignored that issues of ‘race’ and culture are extremely relevant when considering mental health. However, this essay views race as “socially constructed, with little biological validity as a risk factor that fully explains inequalities in health” (Bhui et al, 2005, p.496). What is more feasible and supported in studies such as the EMPIRIC study, is that race is a factor which can be a sociological risk to individuals which can be referred to as racial discrimination having the potential to result in lower self esteem, fewer opportunities, and stress leading to mental health problems (Bhui et al, 2005). In the UK racial discrimination does not just refer to the term ‘race’ as skin colour but also incorporates cultural differences as well (Bhui et al, 2005). Therefore in this essay, when ‘race’ is referred to as leading to mental health problems; it will be in terms of the explanation put forward previously.
It appears that ‘race’ and culture impact on diagnosis, access to services and outcomes. However, this view is based on research obtained in a short amount of time – it was only in 1995 that observing different ethnic groups became obligatory in mental health services which are publically funded (Mind, 2012). However this view is disputed by Glove and Evison (2010) who argue that “differences in the pattern of mental health care received by minority ethnic groups in England have been noted since the 1960s and widely debated since the 1980s”. Irrespective of this dispute, both agree that research has identified differences between different ethnic groups in diagnosis, treatment and availability of services. A common identification in literature is that there are high rates of psychosis (for example schizophrenia) amongst African Caribbean men and apparently low rates of mental illness among South Asians (NCSR, 2002). Influential pieces of research identifying these differences include the Count Me In census which began in 2005 and was created in support of the Department of Health’s five year plan ‘Delivering Race and Equality in Mental Health Care’ (Mind, 2012). The ultimate aim was to reduce admission rates, detention and seclusion amongst black and minority ethnic groups (Mind, 2012). The census identifies that 22% of 30,500 individuals receiving in-patient care were from minority ethnic groups (CQC, 2010). It also highlights that black men are more likely to be detained under the Mental Health Act and that black and black/white mixed race men are three times more likely to be admitted to psychiatric wards and had the highest admission rate of all groups (Mind, 2012). CRITICISM The Fourth National Survey (FNS) of ethnic minorities supports this to an extent. It identifies higher rates of psychosis diagnosis amongst Black Caribbean’s compared to white people (Mind, 2012). However, these differences are lower than previous studies have suggested. Studies undertaken previously have suggested psychosis occurs mostly amongst black Caribbean men however this study suggests higher rates amongst black Caribbean women (Mind, 2012).
Despite these figures, findings have also suggested that Black African Caribbean and South Asian patients are less likely to have their mental health problems detected by a GP (The centre for Social Justice, 2011). Black men have been found to be more likely to be admitted to psychiatric units via the Criminal Justice System (CJS) (NMHDU, 2010). The Count Me in census highlighted that Black Caribbean, Black African and White/Black Caribbean mixed groups are between 40 and 60 per cent more likely to be admitted via the CJS (CQC, 2010). In contrast to this, findings from the census identify that admission rates among South Asian and Chinese groups have remained much lower (below average in many cases) (Care Quality Commission, 2011). This is interesting, as other research has indicated that some specific subgroups of South Asian women (ages 15-24) are at high risk of completed suicide (Raleigh, 1996). Therefore, why are they not getting the necessary support from mental health services?
The EMPIRIC study considers white people as a comparison with Bangladesh, Black Caribbean, Irish, Indian and Pakistani groups (Bhui et al, 2005). This study was undertaken in the community which is quite rare. It considers the impact of racial discrimination in the workplace (Bhui et al, 2005). The study identified that Black Caribbean people reported the highest amount of job denial and Pakistanis the highest level of insult (Bhui et al, 2005). Bangladeshi, White and Irish people were found to be less likely to report discrimination (Bhui et al, 2005). Discrimination in the workplace is common and is a risk factor for common mental disorders (Bhui et al, 2005). The differences between each group in terms of Common Mental Disorders (CMD) were small and there were some variations in terms of age and sex (Bhui et al, 2005). It found CMD were higher amongst Pakistani and Irish men ages 35-54 and higher rates amongst Indian and Pakistani women ages 55-74 (Weich et al, 2004). Common Mental Disorders were found to be lower in Bangladeshi women than white women which is interesting considering this group has the highest level of socio economic deprivation and the accepted link between poverty and mental health (Weich et al, 2004). There were no differences in rates between Black Caribbean and White people despite them suffering the most job denial and this identifies differences to findings from other key studies which often identify higher rates of mental illness amongst black men in particular (Weich et al, 2004). Therefore this suggests this group may be more resilient or Black Caribbean people with CMD may have been excluded from jobs (Bhui et al, 2005). The EMPIRIC study actually identifies that Black Caribbean women had more CMD than Black Caribbean men (Bhui et al, 2005) and as findings from FNS also suggest an area of concern for this group, it appears further research should be undertaken. There are some criticisms on this study being that what is perceived as racism does not always impact on current employment experiences (Bhui et al, 2005). It does not consider the fact that CMD may result in more people reporting racial discrimination (Bhui, 2005). More long term and qualitative studies may be beneficial in understanding the impact of racial discrimination (Bhui et al, 2005). However, studies undertaken late 1990s and early 2000 because there was a raise in concern regarding this issue (partially due tot the Rocky Bennett case) therefore the government commissioned this research due to these concerns. However, in recent years things have died down a bit therefore less research is being undertaken so knowledge is not developing and there is no funding available for researchers.
Despite this, research already carried out seems to follow suite in identifying differences in the diagnosis, treatment and outcomes of mental health for ethnic groups, however these differences are not always on par with each other and identify differences in themselves as already stated (McLean et al, 2003). It is important to understand why variations do exist between ethnic groups in terms of mental health which will be the focus of the rest of this essay.
It cannot be ignored that cultural factors undoubtedly play a role in the findings identified previously. Black and minority ethnic (BME) groups may speak in a way which is considered ‘different’ to white British individuals or they may have dissimilar mannerisms. As a result, this may be interpreted wrongly which could subsequently lead to an incorrect diagnosis of mental health issues (Singh, 2006). As stated “western psychiatrists are more likely to misinterpret behaviour and distress that is alien to them as psychosis” (Singh, 2006). Individuals may be labelled as “strange” or “unusual” because of cultural traits (Singh, 2006). Thus, this identifies that a lack of understanding of cultural differences may impact on interpretations. However, no matter what cultural training people obtain, interpretations of behaviour are always going to vary as cultures are complex and continuously adapting.
Another argument relating to ‘race’ and culture and its link with mental health is that some cultural groups may not react to western-type methods of dealing with mental illness. For example, in Western society, psychiatry is viewed as an objective discipline and therefore the individual receiving the support/therapy is separated from the therapist (Fernando, 2004). It is likely that the therapist will not know the individual and will rarely have any physical contact with them. As put forward “the therapist learns the treatment and applies it within the overall medical model of dealing with problems as individual illnesses, disorders or disturbances of what is assumed to be ‘normal’ mental functioning” (Fernando, 2004, p.121). This way of approaching mental health may be different to other cultures for example where more spiritual methods of healing may be used (Fernando, 2004). As a result, certain ethnic groups may not involve themselves in western methods for example going to see a General Practitioner (GP). Koffman et al (1997) found that in comparison to non-black groups, more black patients who had been admitted were not registered with a doctor. This may be a result of different cultural methods of healing in which western practices do not fit. However, culture should not be considered as stationary or immobile – it does and can adapt and change. It is important to recognise that different cultures can begin to interlink with each other as cultures may react to the environment they are in contact with (MDAA, 2012). This identifies how it can be dangerous to focus too much on culture which I will look into further on in the essay.
Language is a cultural factor which can impact on the right diagnosis and support for an individual: “both diagnosis and treatment are handicapped if there is no common language between doctor and patient” (Farooq and Fear, 2003, p.104). Even when an interpreter is involved, they may not be trained in psychiatry which can limit understanding and can have a negative impact on translation (Farooq and Fear, 2003). However, I would argue that at least if an interpreter is involved, they can bridge the language barrier to a significant extent. As argued “patients in mental health services will experience a better quality of care when accessing interpreters” (Costa, 2011). This is emphasised in the NICE Guidelines for GA, Schizophrenia, Depression and Dementia which puts forward that written material should be translated into different languages and interpreters should be used where appropriate (ref). A mental health professional that comes across a patient of a different culture, who speaks a different language, may not recognise the severity of their symptoms due to the cultural and language differences resulting in lack of support from services for example. Therefore if someone presents to their GP with symptoms these may be misinterpreted if an appropriate interpreter is not present. Therefore although many mental health settings may use interpreters regularly, others may not and the importance of this must be emphasised in order to work through issues of wrong diagnosis, treatment and outcomes of mental health.
Although ‘race’ and culture are evidently pertinent to mental health problems and service responses, it is necessary to consider other factors as “an emphasis on cultural issues can sanitize or mask other issues” (Chantler et al, 2002, p.649). It seems that mental health services are focusing on cultural differences and understanding cultural diversity in an attempt to overcome the differences in diagnosis and support for different ethnic groups. However, in their attempt to do this they may actually be ignoring other key issues thus potentially making the situation worse or at least maintaining it. Some argue that “there is an urgent need to develop cultural competence among nurses and other care workers if they are to meet the needs of the diverse populations they serve” (Papadopoulos, L and Tilki M and Lees S). However, professionals may not treat black people any differently just because they are trained to be culturally aware (Fernando, 2004). There are lots of references to cultural competence in the Department of Health and NHS. The government strategy No Health Without Mental Health which replaced New Horizons in 2011 seems to focus on culture but does not seem to acknowledge important links between race and mental health.
It is well known that there is a significant link between poverty and mental health (Chantler, 2011). It appears that mental health social work is beginning to revolve around the bio medical model therefore social factors such as poverty are not focused on as much as they should (Chantler, 2011). It has been identified that social exclusion can often be a result of poverty as a lack of financial means results in the poorer sectors of society being unable to involve themselves in societal activities thus resulting in exclusion (Gilchrist and Kyprianou, 2011). Social exclusion/isolation can impact on mental health therefore poverty can be viewed as a risk factor for mental health problems (Chantler, 2011). Being in the lowest social class is often linked with poverty and this is something which spans across different ethnicities and cultures. Therefore white, working class members of society may experience mental health issues which are instigated as a result of poverty thus race and culture cannot be viewed as the only factors impacting on mental health – other factors which can also impact on white sectors must be recognised.
However, black and minority ethnic groups may find it more difficult to move into higher classes as a result of issues such as racism and discrimination thus may remain in low socioeconomic circumstances. This highlights a link between poverty and ethnicity and emphasises the concern that peoples race and culture may result in them being forced into situations which could increase their likelihood of mental distress. It appears that there are two main ways racism can impact on individual’s health: the immediate psychological and physical impact and the result of which different races and cultures are not valued within society resulting in social exclusion and disadvantage (Karlsen and Nazroo, 2000). As argued “racism, whether openly hostile or lurking in institutional cultures and practices, limits the opportunities and life choices individuals make” (Gilchrist and Kyprianou, 2011, p.7). Therefore, certain people of certain races or cultures may feel more comfortable remaining in communities together due to racist discrimination or prejudice and as a result may not seek new life opportunities thus potentially remaining in poor socioeconomic circumstances as a result of this forced exclusion (Gilchrist and Kyprianou, 2011). Similarly, discrimination and racism may result in less support within education arenas and less opportunities to excel within employment circles (Gilchrist and Kyprianou, 2011). It has been recognised that unemployment has an impact on mental health (Meltzer et al, 1995). Findings from the Fourth National Survey identify that four fifths of Pakistani and Bangladesh respondents, two-fifths of Indian and Caribbean respondents and one third of Chinese had incomes lower than half the decided national average – recognised as poverty (Karlsen and Nazroo, 2000). This compares to one in four white respondents. Thus, this may be the impact of racism, discrimination and disadvantage (Karlsen and Nazroo, 2000) Therefore there seems to be a vicious cycle whereby BME groups feel the impact of structural oppressions resulting in fewer opportunities to break away from factors which can lead to an increased risk of mental health problems, such as poverty. Therefore, arguably social exclusion, poverty and class could be reasons why there are higher levels of mental illness in some subcultures of South Asian women for example (Karlsen and Nazroo, 2000). The fact that communities ‘stick’ together may result in further antagonism and segregation thus resulting in inappropriate support for mental health problems as ‘outsiders’ may not want to intrude in these cultures – they may take the attitude ‘leave them to it’ which can be very dangerous. Therefore a combination of factors including class and poverty can emphasise mental health issues.
It seems that the role of racism as a risk factor for mental health is being ignored or at least undermined by the coalition government. Although the No Health Without Mental Health strategy acknowledges the need to consider causal factors for mental health, it appears to neglect to discuss the pertinent issue of racism/institutional racism which can be viewed as a downfall in response (Watson, 2011). Therefore, it neglects significant links between race and mental health. This is emphasised in its ‘a call to action’ document, which does not include any BME organisations (Vernon, 2011).
Stereotyping of different groups refers to the discrimination of groups based on views they are certain way. So, South Asian groups may be viewed as having lots of family support and not believing in mental illness. This can be dangerous as it may result in services neglecting to offer support to certain races or cultures. Therefore, it appears that some mental health professionals may inherit views regarding racial stereotypes (Fernando, 2004). Another common racist stereotype is that black men are dangerous which again impacts on diagnosis and treatment. A well known example is that of Rocky Bennett. He was killed in 2004 in a medium secure psychiatric unit after being restrained by up to five nurses and an independent inquiry into this accepted that it was a result of institutional racism (Athwal, 2004). This is not a lone incident and has been recognised as an issue across mental health services. A concern which is shared by many including Richard Stone (a member of the Bennett inquriy panel) and Errol Francis (a campaigner on black mental health) is that cultural/racial awareness training will not reduce institutional abuse, it must be acknowledged and then the behaviour of the professionals and workers needs to change (Athwal, 2004). Once understood and acknowledged, progress can be made to tackle and understand causes (McKenzie, 2007). McKenzie (2007) put forward concern that the importance of Delivering Race Equality would be undermined, which seems to have been the case in No Health without Mental Health as it does not seem to recognise the importance of racism as a risk factor for mental health and the impact it has on service responses (Watson, 2011). Watson (2011) argues that “the impression given is that we are moving to a post-racial big society where ‘state multiculturalism’ is expunged from British values and public consciousness…” Thus the link is being undermined and if this is the case it is unlikely changes will be made.
Chantler et al (2002) undertook a ten month qualitative study with a group of South Asian women who are survivors of self harm or attempted suicide. It seems that survivor’s highlighted issues causing mental distress including immigration status, poverty, and domestic violence in their accounts however an over focus on cultural sensitivity by professionals and policy makers means that these factors often goes unrecognised (Chantler et al, 2002). Also, important to note is that there does not seem to be much research into the fact that if people are seeking asylum, there is a possibility that their mental health needs may be higher as a result of their experiences prior to migration (Chantler, 2011). As a result of lack of recognition, inappropriate or a lack of support was offered by services. The researchers found that the survivors who had been seeking asylum mentioned policies such as the ‘one year rule’ as causing them distress and oppression as it meant they were trapped (often in an abusive relationship) for a long period of time without a chance of escape (Chantler et al, 2001). As stated, “current immigration legislation strips South Asian women of the legal and personal support available to white British female citizens” (Chantler et al, 2002). The survivors identified that they felt these policies ensured that all power was given to the man (Chantler et al, 2002). Policies implemented trying to overcome problems in services by employing South Asian workers needs to be looked into (Chantler et al, 2002). It seems that policy makers used cultural clashes as explanations as to why issues such as domestic violence, immigration issues and poverty were not highlighted (Chantler et al, 2002). Thus in models of mental health, factors such as immigration are neglected. Services claimed to be unable to meet their needs due to cultural conflict (Chantler et al, 2002).
All but one of the survivors in the study had suffered domestic violence identifying the link between domestic violence, immigration status and suicide/self harm (Chantler, 2001). It is worth noting that refugees and asylum seekers may have experienced traumatic events before arriving in the UK such as war and poverty therefore they may have higher mental health needs because of their experiences – this is not covered much in research and is something which may be beneficial in our understanding.
Burman et al (2005) focuses primarily on domestic violence services with regards to African, African-Caribbean, South Asian, Jewish and Irish women, it became evident that culture was seen to be more important than dealing with domestic violence issues. Thus a focus on culture can be seen as an obstruction to offering the appropriate support (Burman, 2005). The study also identifies how other issues such as immigration policies prevent asylum seeking women from being able to leave abusive relationships therefore this needs to considered more (Burman, 2005). “racialised dimensions of such policies heightens their exclusionary effects”. The outcome of these findings suggests that there needs to be new ways of supporting women from minoritised groups suffering domestic violence (Burman, 2005). Criticisms of study?
It seems that in favour of culture, gender issues such as violence against women are often ignored in relation to minority ethnicities (Chantler, 2002). Would this be the case if it were white women? What is interesting is that violence against women is considered a gender issue in relation to white women but is seen as a cultural issue in relation to South Asian women (Chantler et al, 2002). This is something which needs to be recognised and changed. Cultural factors need to be acknowledged to a degree and particularly in certain circumstances for example honour based violence, however it needs to be recognised that culture and race are not always at the forefront of issues. It is important to move away from a complete focus culture in many instances, and consider gender issues as well. Segregating women from minority groups from white women with regards to violence can lead to lack of support thus potentially resulting in self harm/attempted suicide amongst other issues, as a result of the mental distress. The research undertaken by Chantler et al (2001) and Burman (2005) highlight this.
As a social worker it is important to recognise cultural differences and be open about culture so that interventions are not so difficult however, although being culturally aware is useful, it is impossible to recognise all factors as cultural as there are numerous different cultures which are constantly adapting. Also, as this essay has identified, an over focus on culture can be dangerous. It is important to be conscious of other risk/causal factors of mental health such as violence against women, class and immigration status. It is essential label or stereotype someone based on their race or culture but rather engage, empower and empathise with service users. As Chantlers’ 2001 study identified, regardless of a service users race or culture, they often just want someone to listen to them. Do not always presume it is about culture as policy has tended to do in recent years. It seems that a combination of structural, cultural and individual factors including gender, poverty and culture will enable a greater understanding of diagnosis, treatment and outcomes of mental health. Considering one without the other will limit understanding. Therefore, knowledge needs to be more nuanced. I am not undermining the importance of race and culture in relation to mental health and service responses, as I have acknowledged its importance in this essay. However, do not neglect other equally important factors.
Also gender issues need to be considered for example domestic violence. Why is domestic violence considered cultural only when related to certain ethnicities e.g south Asian women??
SOME violence crimes are specific to certain cultures for example honour based violence, trafficking (UMHDU, 2010)
However, all ethnicities within the uk experience gender based violence not just certain ethnic groups and evidence suggests that violence and abuse cause mental health issues (UMHDU, 2010). However it is sometimes only seen as a gender issue when it is white women suffering abuse. Seen as a cultural issue when minority ethnic group.
Maybe it isn’t a cultural issue but a gender issue??
Research by Chantler et al – many women from different ethnicities don’t mention culture/race in their study – just