Fifteen Eighty Four

In all stages of psychopathology — the expression, experience, development, outcome, help-seeking and treatment interventions — culture is central. [1] Definitions of culture vary enormously and are often contested but, for the purposes here, is taken to mean the norms, practices and values of a group. Cultural psychiatry evolved to meet precisely this imperative of placing culture at the centre of mental health care. Its evolution can be charted in three main stages (Kirmayer and Minas, 2000, 438–9). The first stage occurred during periods of colonialism and involved encounters with non-Western cultures, where the latter purported to represent cultural difference, pathologized in the conceptualisation of ‘culture-bound’ syndromes. The second stage involved adjusting to ethnically diverse populations in the Global North, a result of post-war migration. And this diversification led to the need, that remains pressing, for a psychiatry that recognises the significance of cultural differences within multi-ethnic populations. The third stage recognised the importance of considering cultures from within their frames of reference.

The General Medical Council’s 2018–2020 equality, diversity and inclusion strategy argues for the importance of ‘doctors [being] able to use their diverse backgrounds and experiences to deliver innovative care that can respond to the diverse needs of their patients’ www.gmc-uk.org/-/media/documents/edi-strategy-2018-20_pdf-74456445.pdf, 4). This seems disingenuous. The sea change in GMC policy in the late 1970s meant that qualifications from South Asian countries were no longer recognised (Smith, 1980, 11-12) and that doctors had to undertake retraining of some kind in order to meet the requirements for registration. This policy change cannot be decoupled from the history of colonialism and it implies that overseas qualifications (read as: standards) from certain countries were below par.

Journey to the Centre of the Self: Exploring the Lived Experiences of South Asian Psychiatrists in the UK sees what we can learn from the experiences of this significant class of doctors, who have contributed so much to the healthcare of the nation. Cultural psychiatry promotes the essentiality of reflection – on one’s culture and biases as well as that of the patient– to meet the needs of a multi-ethnic population. One focus in the literature has been on ethnic minority groups. Less attention is paid to the identity of the healthcare practitioner, an assumption that can be explained by white privilege, that is, the problem of normative white bias. The default assumption – that the psychiatrist is white, or that the identity of the psychiatrist has no bearing – leads to the grave oversight of the quite different implications that may arise if the psychiatrist is from a non-white ethnic minority background. The non-white psychiatrist risks racism and other forms of discrimination as well as issues they might face when, for instance, treating patients from an ethnic background similar to their own in terms of expectations and boundaries. This default assumption also fails to recognise what is distinctive about the contribution of the ethnic minority psychiatrist, what they can bring with respect to knowledge, experiences, and skills.

This book undermines assumptions about the therapeutic dyad by hypothesising what would happen if the psychiatrist was from a non-white ethnic minority background — here South Asian — and invites thirteen psychiatrists matching this broad ethnic profile to speak about their experiences. We acknowledge that South Asia is a large geographical region with great variations in culture and with this, a plurality of identity. In the lived account of these professionals, we learn about the deft ways in which they negotiate the conventions of two very different cultural identities, broadly speaking, South Asian and British. Their narratives of migration, where migration was interpreted as more than a historic event but an ongoing process of adaptation and change, involved hardship of many kinds. Having to leave behind their homelands and manage cultural difference helped develop skills of empathy. Second-generation psychiatrists born in the UK may not have had to undergo the physical event of migration, but they had to acclimatise themselves to the existential realities of living within two (or more) cultures with markedly different values. Their experiences of learning how to fit in, especially in the cases of first-generation psychiatrists, enabled them to build up rapport with patients in a similar situation of displacement, such as those from migrant populations from South Asia, Central Europe and beyond.

Understanding the cultural mores of South Asian culture was advantageous to the psychiatrists insofar as they had insight into which approaches might be more conducive for treating these populations. In addition to the more established prior research about the attitudes of South Asian groups to mental health, such as the concept of stigma and the tendency for somatization, are newer findings that alert us to the informal and unofficial ways in which South Asian patients accessed help. One of the primary objectives of the book was to address the low uptake of mental health services amongst South Asian populations and to investigate barriers to provision. What was elicited in the interviews was that support is accessed but in ways that bypass official channels such as consulting one’s GP followed by a referral to a psychiatrist. What happened instead is that psychiatrists were contacted via social media by members of their communities seeking help typically for a family member.      

Being able to converse in their mother tongue (or first language) proved to be invaluable in the therapeutic process and was explored widely in the interviews. Particularly when in states of mental distress, people are more inclined to converse in their mother tongue. Whilst the provision of translation services may be beneficial, it is no substitute for the conversation between two speakers sharing the same or similar first languages. Within a clinical setting in the UK, the value of a South Asian being able to converse in a more familiar ethnic language cannot be underestimated. This is not without its problems, however, and can result in attempts by the patient to be overfamiliar and skew the professional boundaries appealing instead to a relationship based on ethnic kinship, for instance.

The interviews in this book also revealed the ways in which the psychiatrists had to contend with discrimination of different kinds, most often manifested through the attitudes of patients or colleagues in both overt and implicit ways. The experience of being ‘othered’ by the question, ‘Where are you from?’ potentially threatens the power dynamic in the therapeutic relationship. It carries with it an implied sense of difference especially if accompanied by the follow-up, ‘No where are you really from?’

The interviews were methodologically important as they provided a platform for the psychiatrists to speak for themselves. They also generated a seam of rich material that conveyed the contribution of South Asian psychiatrists to the profession. The participants did not view their knowledge or understanding as especially important, which could possibly be because it differed from Western epistemological frameworks that placed a premium on certain paradigms such as evidence-based science. But in fact, understanding indigenous practices such as Ayurveda and behaviours including the entwinement of religion and medicine, is integral to South Asian mental health.   

This pioneering book is consciousness-raising about the invisible stories of generations of psychiatrists who have been working in the UK. Discourse on cultural psychiatry seeks to make practitioners more culturally aware. This necessitates two steps. Firstly, the recognition of white privilege and the impact this has on institutional policies and practice and, secondly, what we can learn from the marginalised groups themselves. In addressing the barriers to the uptake of mental health services studies have sought the views of patients but not psychiatrists from these groups, which is remiss. This highlights a gap in the literature which needs vitally to be addressed in Britain’s increasingly ethnically diverse population. And, crucially by exposing white privilege, cultural issues become viewed not as problems that need fixing but rather frameworks that need to be understood and worked with.

References

Kirmayer, L. J. (2012). ‘Rethinking cultural competence’. Transcultural Psychiatry, 49.2, 149–64.

Kirmayer, L. J. and Minas, H. (2000). ‘The future of cultural psychiatry: An international perspective’. The Canadian Journal of Psychology, 45.5, 438–46.

Smith, D. J. (1980). Overseas Doctors in the National Health Services. London: Policy Studies Institute.

Title: Journey to the Centre of the Self

ISBN: 9781316514597

Authors: Rina Arya and Dinesh Bhugra