Cultural Psychiatry: Surveying the Field
Cultural psychiatry is concerned with the cultural aspects of psychopathology and the role of culture in the development, expression and outcome of mental health. More fully, ‘[c]ulture influences the experience, expression, course and outcome of mental health problems, help-seeking and the response to health promotion, prevention or treatment interventions’ (Reference KirmayerKirmayer, 2012, 149). It is inherently interdisciplinary and draws from anthropology, sociology and psychology amongst other disciplines. Laurence J. Kirmayer discusses how, ‘unlike the social sciences of medicine’, cultural psychiatry is driven ‘primarily not by theoretical problems but by clinical imperatives’ (Reference Kirmayer, Bhugra and Bhui2007, 3). This needs to be emphasised because it explains many features of the field, including the extent to which research has been generated in the clinical encounter.
The term ‘transcultural’ is used by some interchangeably with ‘cultural’ in ‘cultural psychiatry’ but by others in place of it. Eric Wittkower adopted the term ‘transcultural’ to ‘imply moving through and beyond cultural barriers’ (Reference Wittkower and RinWittkower and Rin, 1965, cited in Reference Kirmayer, Bhugra and BhuiKirmayer, 2007, 13). His endeavours, from the mid-1950s onwards, led to the setting up of various committees and societies and the founding of journals of transcultural psychiatry. Kirmayer cites Raymond Prince, from Reference PrincePrince’s 1997 article ‘What’s in a name?’, as an example of someone who uses the term ‘cultural psychiatry’ to indicate ‘that all human experience is culturally constituted and that we can examine cultural meanings in a single society as well as comparatively’ (Reference Kirmayer, Bhugra and BhuiKirmayer, 2007, 13). Cultural psychiatry was believed to have a broader remit, to be inclusive of the transcultural and to be fundamentally committed to examining culture in a more encompassing way (see also Reference Dein and BhuiDein and Bhui, 2013, 770).Footnote 1
One of the main objectives of cultural psychiatry is the inculcation of a stance of self-reflexivity with respect to culture and cultural difference, which has as its aim the production of culturally competent – some prefer, culturally capable – practitioners. Cultural psychiatry advocates reflexivity about the cross-cultural aspects of mental health and illness, is concerned with understanding how psychopathology is defined and treated in various cultural contexts, and seeks to develop culturally sensitive diagnostic and therapeutic approaches. Relativism about culture is the view that the mind and mental illness are understood and conceptualised in different ways depending on the cultural tradition in question. This raises questions of a philosophical, epistemological, technical and practical nature, which are addressed in the reformist thinking central to the discipline. What constitutes good clinical practice in one setting may not apply in another, given the importance of context-specific understanding. That being said, practical reasons necessitate the implementation of classificatory systems. Within psychiatry the International Classification of Diseases (ICD) and Diagnostic and Statistical Manual of Mental Disorders (DSM), the former currently on its eleventh edition and the latter its fifth (DSM-5), are recognised internationally as authoritative but should not be regarded as value-free (in the sense of being free of bias) (see Reference Mezzich, Kirmayer, Kleinman, Fabrega, Parron, Good, Lin and MansonMezzich et al., 1999). In keeping with the emphasis on the centrality of culture is the view that regardless of the cultural makeup of the geographical region of clinical practice, healthcare practitioners should be able to administer care that is culturally sensitive.
A more elementary question, and one that is useful here, is the very definition of culture itself. ‘Culture’ is a broad term that has been defined and deployed in many ways by scholars from different academic disciplines. Reference LenardPatti T. Lenard’s (2020) entry in the Stanford Encyclopedia of Philosophy is comprehensive. She describes how culture refers to the norms, practices and values that characterise groups. That being said, the boundaries between cultures are porous and people belong to multiple cultures. Lenard highlights the human element to her discussion, arguing how cultures matter to people: they help shape experiences and values, and create meaning. The definition of culture in the DSM-5 is also broad and inclusive, and recognises that:
Cultures are open, dynamic systems that undergo continuous change over time; in the contemporary world, most individuals and groups are exposed to multiple cultures, which they use to fashion their identities and make sense of experience.
From its inception, cultural psychiatry has focused mainly on the cultures of ethnic minorities, particularly non-white minorities. The way in which culture is framed varies. In the United States, it is framed predominantly in terms of race, whilst in the UK it is ethnicityFootnote 2 (see Reference Bhui and SinghBhui and Singh, 2004, 125; Reference KirmayerKirmayer, 2012, 154). The relative merits or demerits of looking at race rather than ethnicity or vice versa are not as critical as the point that culture is much more than race or ethnicity. National census categories may allow for multiple choices but are essentially limited in that they ‘do not capture the diversity of the society and the rapidly growing numbers of people who define themselves in hybrid ways that cut across these categories or escape them entirely’ (Reference KirmayerKirmayer, 2012, 154).Footnote 3 Culture should be viewed instead as open, fluid and in a state of change (Reference KirmayerKirmayer, 2012, 154).Footnote 4 The authors build on this line of thinking and believe what needs to be advanced is an understanding of the identity of a person of a non-white ethnic minority as composite and multifaceted, and inclusive of different components, such as the plural understanding of culture that comprises variables that may comprise ethnicity, race and so on, including social determinants (Reference AntićAntić, 2021, 364, 369).Footnote 5 The recognition of the complex nature of individual identity is required for understanding cultural heterogeneity, namely the idea of diversity within group identities. And adding to that is the idea that people belong to multiple cultures (Reference LenardLenard, 2020).
Before moving on, a reminder of the rationale for thinking about culture in relation to minority groups is useful. The imperative of cultural psychiatry was to develop a more culturally reflective understanding of global mental health in the light of the dominance of the Western perspective on the discipline of psychiatry. Developed historically from colonialist practices, psychiatry espoused Western traditions and values. Those outside of these traditions were subject to structural racism and pathologisation. In contemporary society, these groups continue to experience political, social and economic disadvantage and often have more precarious relationships with mental health services. The shift towards looking at cultures in their own terms in cultural psychiatry provides a corrective to outmoded practices. In a position statement about psychiatry in the era of decolonisation, Ana Reference AntićAntić (2021) celebrates the contribution of psychiatrists from ethnic minority backgrounds, whom she believes have become adept at examining cultural identity in a more holistic way than more established traditions.
An overview of the historical development of cultural psychiatry is worth considering before looking more specifically at the UK picture. The progression of cultural psychiatry can be mapped in stages (Reference Kirmayer, Bhugra and BhuiKirmayer 2007, 4–8; Reference Kirmayer and MinasKirmayer and Minas, 2000, 438–9). The first stage involved the encounter between European and non-Western cultures during colonialist missions and expeditions. The discipline of cultural psychiatry emerged out of the legacy that colonialism had on the mental health of the cultural ‘other’, a narrative that Reference Kirmayer, Bhugra and BhuiKirmayer (2007), amongst others, underscored as imperative to its evolution. Notwithstanding this, Reference Mahone and VaughanSloan Mahone and Megan Vaughan (2007) warn against exaggerated accounts of grand colonialist schemes, arguing that reports of psychiatric practices in colonial contexts should not be conflated with the intellectual history of imperialist psychiatry (2). That is not to deny the brutality of colonialist psychiatry but rather to demystify narratives that concocted elaborate schemes of institutionalisation. What actually went on was the exercise of the imperialist mindset that colonised in the name of ‘civilisation’. The rationale was that it was in the interests of the colonialised to be ‘civilised’, ‘for their own good’, and this responsibility fell to the white colonialists, a duty subsequently described as ‘the white man’s burden’.Footnote 6 The violence of colonisation was not only seen in physical actions such as the taking of land but also in the psychological damage, which is no less harmful (see Reference Price, Dwyer and NettelbeckPrice, 2018; see also Reference Mahone and VaughanMahone and Vaughan, 2007).
In broad terms, colonialism involves forcible change in the colonised of their culture, habits integral to identity and wellbeing. The philosopher and psychiatrist Reference FanonFrantz Fanon (1986, 191–5) studied the psychopathological effects of colonialism, what he termed ‘cultural imposition’, on the colonised who were unable to transcend their fate. He conveyed in vivid terms how the colonised suffered under regimes of control that had devastating impacts on identity. This is conveyed trenchantly: ‘Madness is one of the means man has of losing his freedom. And I can say, on the basis of what I have been able to observe from this point of vantage, that the degree of alienation of the inhabitants of this country appears to me frightening’ (Reference FanonFanon 1964, 53). Fanon is a figure of great significance in cultural psychiatry and his method of reflecting on the lived experience of himself as the ‘other’, an African-Caribbean person under French colonialism, and the insight this gave him into his patients’ lives make his work essential.
The second stage of cultural psychiatry involved adjusting to a postcolonial world. Mass migration and postwar development across the globe after the fall of empire in the twentieth century transformed societies, especially in parts of the West/Global North. The movement of migrants, refugees and exiles continues today, creating increasingly culturally diverse populations. The mental health needs that arose were attributed to the stressors of displacement, whether through migration, forced exile or other processes, including the continuing effects of colonialism. The term ‘postcolonial’ may be used to signal the official end of imperialist regimes but it also acknowledges the aftermath of these histories.
The third stage, which continues to the present day, is the anthropology of psychiatry; that is, ‘the ethnographic study of psychiatry itself as the product of a specific cultural history’ (Reference Kirmayer and MinasKirmayer and Minas, 2000, 438). This involves looking at cultures from the inside, ethnographically, where culture is interpreted in its own terms, by the standards and conventions of the culture in question rather than by any other. This method mitigated against ethnocentrism and exposes the cultural production of knowledge and, concomitantly, power. Its trajectory is paralleled by the transformation undergone in anthropology.
Classical Western anthropology arose from imperialism and ‘emerged as an attempt to scientifically classify groups of human beings as different and therefore separate’ (Reference PelsPels, 2008, 280). During fieldwork visits to remote places, knowledge was construed in terms of a binary between the anthropologist-as-investigator and the object of enquiry. The crisis of representation in the 1980s and 1990s within the human sciences was part of a larger critical turn arising from postcolonial thought that necessitated a shift in thinking about legitimate modes of enquiry which problematised previous practices. The process of representing other cultures was not to be seen as an exercise of excavating truth, where the bearer of knowledge, in this context, the anthropologist, ‘discovered’ a culture in absolute terms. Instead the culture should be described from the perspective of the anthropologist. Advocating a ‘self-critical’ reflexivity (Reference Clifford and MarcusClifford and Marcus, 1986, 24) to prevent cultural domination, the process of representing other cultures was to be understood as ‘inescapably contingent, historical and contestable’ (Reference Clifford and Marcus1986, book summary).Footnote 7
The above developments in the stages of cultural psychiatry have led to ratified changes mandated by professional bodies, as seen in the progression of ideas from the DSM-4 (1994) to DSM-5 (2022). The transition evidenced here involved the reconceptualisation of culture where it was not seen as the preserve of minority groups (as reflected in the hugely problematic notion of ‘culture-bound’, in DSM-4) to an understanding, in DSM-5, that everyone has and belongs to different cultures and these cultures shape value systems. This transition included unpicking the culture of the institution of psychiatry, which was equivalent to white, Western culture. Making the culture of psychiatry visible was an indispensable move in the development of cultural psychiatry.
Cultural psychiatry has made great strides in its development. Early scholarship focused on delineating the academic and clinical concerns of the discipline, which included articulating the history, theory, methodology and practice of the discipline. The scope of interests and methods is wide: of overriding importance for professionals is the adoption of a sensibility, that is, a stance of cultural reflexivity and sensitivity. The migration histories of different populations are reflected in the variation of trajectories and priorities that cultural psychiatry has taken. Nonetheless, there are various threads that are common across contexts, which include the impact on mental health of migration and structural racism in society and its forms of disadvantage to ethnic minority groups (Reference Littlewood and LipsedgeLittlewood and Lipsedge, 2014; Reference FernandoFernando, 1988).
Research in Cultural Psychiatry: The UK Context
The history of British imperialism has been integral to understanding the priorities of cultural psychiatry in the UK. This encompasses the aftermath of the fall of empire, which included the postwar influx of migrants from Commonwealth countries that led to the growing diversity of what is now a multi-ethnic landscape. Cultural psychiatry in the UK has been oriented toward examining the impact of migration across generations, which includes thinking about processes of acculturation. The approach taken is twofold, with some overlap between the two components: the recognition of the effects of racism and discrimination on mental health, and, relatedly, efforts to achieve services that meet the needs of ethnic minority groups. Research thus far has concentrated mainly on particular minority groups (Reference Littlewood and LipsedgeLittlewood and Lipsedge, 2014, 258) including South Asians.
The contribution of key figures within the development of cultural psychiatry is a useful starting point for exploring the terrain. One of the earliest studies, Race, Culture and Mental Disorder by Reference RackPhilip Rack (1982), came out of his work in Bradford with the MirpuriFootnote 8 community on the basis of which he established a specialist centre to cater for its cultural needs. Reference Littlewood and LipsedgeRoland Littlewood and Maurice Lipsedge’s (2014) Aliens and Alienists: Ethnic Minorities and Psychiatry, originally published in 1982, is regarded as a classic text that examines the relationship between racism, mental health and the treatment of ethnic minorities, and consists of case studies of diverse groups including African-Caribbeans, Turkish Cypriots and Hasidic Jews. Another early important study was Reference CoxJohn L. Cox’s (2020) edited book on Transcultural Psychiatry (originally published in 1986), which looked at different aspects relating to the needs and backgrounds of ethnic groups.
One of the early pioneers of cultural psychiatry within the UK was Reference FernandoSuman Fernando (2017), whose Institutional Racism in Psychiatry and Clinical Psychology, amongst his numerous publications in this field, gave an overview of the problems faced by ethnic minority (excluding white minority) psychiatrists in the UK and of the changes in mental health care, particularly throughout the later part of the twentieth century. Very much an activist, he spoke of the ‘race-based’ glass ceiling in relation to the appointments of senior staff through the 1960s to the 1980s and set up the Transcultural Psychiatry Society (TCPS), which was critically important in campaigning against racism in mental health services both in terms of the difficulties encountered by the said professionals and ethnic minority (excluding white minority) users of mental health services (Reference FernandoFernando, 2017, viii, 114–16). With a membership comprising mental health professionals from a variety of cultural backgrounds, all with a shared motivation to address the importance of culture in discussions about mental health, the efforts of this group brought about change, with an increase in the appointments of ethnic minority psychiatrists in the 1990s. Another early figure of profound importance was the psychiatrist Aggrey W. Burke, also well known for his activism. He researched the role of racial discrimination in psychiatric disorders (Reference BurkeBurke, 1984, Reference Burke and Cox1986). His work in the 1980s showed how deprivation is associated with mental illness, which he uncovered especially within black communities. In 1986, together with his colleague, Joe Collier, he published a paper that showed racial and sexual discrimination in admission to London’s medical schools (Reference Collier and BurkeCollier and Burke, 1986; see also Reference AndrewsAndrews, 2022).
One of the pre-eminent figures in the field of cultural psychiatry in the UK is Dinesh Bhugra, who has numerous accolades and is a leading figure in the social justice of mental health care. Emeritus Professor of Mental Health and Cultural Diversity at the Institute of Psychiatry, Psychology and Neuroscience at King’s College, London, his contribution to the field is extensive and his output prolific. His role encompasses clinical practice, research, teaching and activism. His global work involves the implementation of training and education into low- and middle-income (LAMI) countries, and demonstrates the importance of acknowledging relativity about culture. His philosophy aligns mental and physical health and endorses his core value of holistic medical care.
He has authored and edited numerous books in the field, notably the award-winning Textbook of Cultural Psychiatry (2007). Not to be overlooked are his more practical texts on how ‘to do’ cultural psychiatry that provide clinicians with case studies and examples (see Reference Bhugra and CochraneBhugra and Cochrane, 2001; see also Reference Bhugra and BhuiBhugra and Bhui, 2001). One of the most significant areas of his research is his writing on the impact of migration on mental health. Bhugra’s personal journey of migration began as the son of migrant parents who fled to India from Pakistan during the Partition, and continued when he became a first-generation migrant in the UK. The special significance of migration, within the field of cultural psychiatry, underscored by Bhugra, explains one of his special interests in the mental health of refugees and asylum seekers (Reference Bhugra, Craig and BhuiBhugra et al., 2010; Reference BhugraBhugra, 2004a). The range of topics within his scholarship are wide-ranging. He also draws on first-hand insights of the needs of South Asian communities (see Reference BhugraBhugra, 2004b, for example). One of the most comprehensive studies in this area is his 2005 volume Handbook of Psychiatry: A South Asian Perspective, which is an extensive examination of clinical practice in South Asia.
Bhugra has spoken about the need for a broader approach to medical education, in which he considers the humanities and arts as integral (Reference JonesJones, 2018, 531; Reference BhugraBhugra, 2003). His postgraduate qualifications in sociology and social anthropology support his approaches and methods used in the humanities and social sciences, broadening the approach to mental health by looking beyond the medical model to incorporate other perspectives (see Reference MohammadiMohammadi, 2017, 746). This involves widening understanding about the relevance of culture in mental health, and appreciating that cultures have different means of evaluating behaviours and providing support (see Reference BhugraBhugra 2006; Reference Deakin and BhugraDeakin and Bhugra, 2012).
Current research in the field should be considered against the backdrop of continual change in the ethnic makeup of the UK, including the flow of migrants and other groups of people from different parts of the world in response to socio-political events. The impact of migration on mental health and on racism are ongoing themes in the literature (Reference Dein and BhuiDein and Bhui, 2013, 769). The research by pioneers in the field in the UK, such as Rack in Bradford, Roland Littlewood in Birmingham, and Julian Leff in London, helped identify specific ethno-cultural groups by region. Building on this, the development of the subjective views of ethnic minority groups in their experiences of healthcare provision is vital (Reference Dein and BhuiDein and Bhui, 2013, 771, 769). It represents a turn to members of ethnic minority groups, rather than those outside of them, to gather their testimonials and other information. The greater focus on circumscribed identities and topics helps mitigate oversimplified understandings of both people and their cultures. This needs to be seen against the backdrop of the psychiatric survivor movement, a global coalition of individuals that emerged in the late 1960s that claimed they ‘survived’ a mental health system that was purportedly designed to help them (see Reference EverettEverett, 1994).
Reference Prajapati and LieblingRiddhi Prajapati and Helen Liebling’s (2022) systematic review presents a comprehensive overview of research consisting of fifteen studies carried out in the first two decades of this century. The demographic data is useful in its identification of cohorts, including ethnicity, gender, faith traditions, age, location and generational status (Reference Prajapati and LieblingPrajapati and Liebling, 2022, 602–8).Footnote 9 A range of areas of investigation are identified concerning various stages of clinical practice including service users’ perceptions of quality of care and their experiences as patients. More troubling, however, are the enduring problems resulting in continuing barriers to engagement in mental health services for South Asian populations. These are in spite of governmental initiatives and investment. The problems discussed in this study are twofold and involve the barriers to care, some of which were due to cultural norms that prevented those in need coming forward in the first place (Reference Prajapati and LieblingPrajapati and Liebling, 2022, 609), and, running in parallel with this, the inadequacies of the current ‘Eurocentric’ system that insufficiently addresses the needs of more diverse groups (Reference Prajapati and LieblingPrajapati and Liebling, 2022, 599). Prajapati and Liebling call for serious action to prevent the inequality gap from widening further, emphasising the need for greater attention to this area in future research. This is especially important given the increase in the South Asian population in England and Wales from 3.9 per cent in 2001 to 5.3 per cent in 2011 and 6.9 per cent in 2021.Footnote 10
A substantive area that would benefit from greater research, especially in the context of South Asian populations, is religion, spirituality and mental health, the importance of which is recognised by Reference Dein and BhuiDein and Bhui (2013, 773; see also Reference Dein, Cook, Powell and EaggerDein et al., 2010). Religion and spirituality in its various forms and traditions contribute much to human life and meaning, and this has been addressed in a number of studies that address the subject in relation to global traditions and practices (Reference Moreira-Almeida, Mosqueiro and BhugraMoreira-Almeida et al., 2021) and within specific religio-cultural traditions (for example, Reference Dein, Alexander and NapierDein et al., 2008). The relevance of religion and spirituality to mental health within South Asian culture was brought up by some of the psychiatrists in their interviews and will be discussed in Chapter 8.
The remainder of this chapter addresses two strands that need further examination and which are of central importance to this book. These are the need to take seriously (1) the diversity of identity positions within ethnic minority populations, thereby recognising the importance of cultural hybridity, notably in a globalised world, and (2) the perspectives of South Asian psychiatrists in the white spaces of psychiatry and the implications this has on practice. These concerns invite critical thinking from disciplines relevant to cultural psychiatry including anthropology, sociology and cultural studies, and turn the focus to look at questions about representation, power and the production of knowledge.
Strand 1: The Diversity of Ethnic Minority Identity
One of the outcomes of mass migration, especially involving ethnic minority (excluding white ethnic minority) groups, is the tendency to view migrant populations exclusively through the lens of ethnicity or race without consideration of the diversity of identity positions. This is also one of the legacies of colonialist practices within anthropology. The limitations of conceptualisations of cultural identity within psychiatric literature have been noted elsewhere (Reference Dein and BhuiDein and Bhui, 2013, 781; Reference KirmayerKirmayer, 2012, 154). It is vitally important in ethnographic research on cultural minorities to construe ethnic minority identities holistically and dynamically, in the interests of providing deeper understanding and, within a clinical perspective, better care. This leads to representations that are complex and multilayered. Martin Jay argues that ‘ethnocentric definitions of collective subjectivity … come up against the problem of conflicting affiliations, which cut across any coherent notion of solidarity’. He goes on to say, ‘No one, after all, is just, say, a worker, a Catholic, a woman, a heterosexual, an Italian-American and so on, but at the unstable nodal point of such overlapping identities, all of which may pull in different directions’ (Reference JayJay 1994, 236). The greater the awareness of the multiple components that make up identity, and the way they present, the closer the clinician can get to a more well-rounded understanding.
The Politicisation of Black British Identity
The problem thus far has been the tendency to conflate non-white ethnic minority identities, as seen in the configuration of BAME identities, often in the interests of expediency, such as to roll out services and so on. The acronym BAME (black, Asian and minority ethnic) refers to people of non-white ethnicities who are minoritised in the UK, replacing the term BME (black and minority ethnic).Footnote 11 The collective classification of non-white minorities in the UK occurred in the late 1970s as a politics of anti-racism and conveyed a sense of shared consciousness, an identity constructed, not given (Reference MercerMercer, 1994; Reference ChambersChambers, 2016). The term Black, often capitalised, came to symbolise political identity that united non-white minorities, those with African, Caribbean or South Asian origins, through a common experience of racism within the UK. This activism of coming together in the interests of collective struggle represented a powerful moment in British history (see Reference BrahBrah, 1996). But it came at a cost. The group identity failed to capture the diversity of its members. Reference ModoodTariq Modood (1994, 873) was amongst many who argued against the term on a number of grounds, including the harm it caused to Asians and the way in which it distorted the analysis of sub-ethnic identities and interests (see also Reference MistlinMistlin, 2021a).
Stuart Hall and New Ethnicities
The work of Stuart Hall, one of the founding members of what came to be known as British Cultural Studies and the ‘leading theorist of black Britain’ (Reference AlexanderAlexander, 2009, 457–8), is critical in thinking about postwar black British identities.Footnote 12 His influence on cultural psychiatry in the UK has also been acknowledged (Reference FernandoFernando, 2017, 115). The tendency of cultural psychiatry to conflate culture with ethnicity or race invariably led to the over-identification of individuals from black or South Asian backgrounds, for example, with ethnicity or race, depriving them of a fuller exploration of identity. It also resulted in an understanding of culture as that which is minoritised, crudely speaking, the ‘other’ (Reference Littlewood, Bhugra and CochraneLittlewood, 2001, 18).
Drawing from his first-hand experience of otherness, which he underwent in his Anglicised colonial education in Jamaica, and then of the changing landscape of multiculturalism in the UK, Hall spoke of the need to resist essentialising the black experience and described identity as a dynamic process that is instead shaped by social, historic and political forces. His theorising about New Ethnicities problematises black essentialism (that is, the black experience as a singular framework), and argued for the imperative of looking at identity more holistically in relation to other identity variables including class, gender and sexuality (Reference Morley and ChenMorley and Chen, 1996, 442–51). Originally delivered as an address to the conference Black Film, British Cinema in 1988, which brought together filmmakers, artists and critics to discuss what it meant to be ‘black’ and ‘British’, Hall’s ideas inspired a generation of creatives in film, art and other media.Footnote 13 He explored the diversity of black experiences and subject positions (Reference Morley and ChenMorley and Chen, 1996, 9) with ‘the focus on indeterminacy, contingency, subjectivity, multiplicity and agency, on “becoming” not “being”, on difference’ (Reference AlexanderAlexander, 2009, 473).
This more fluid understanding of ethnic minority identity positions gives a richer picture of an individual’s traits and preferences. It also conveys socio-political identity, how aspects of a person’s identity combine to create points of similarity and dissimilarity, advantage and disadvantage, the theory of which is known as intersectionality. Coined by Reference CrenshawKimberlé Crenshaw (1989, 140), intersectionality examines the extent to which the intersection of race with other identity categories, such as gender and class, affects the degree of privilege experienced by an individual. It examines the ramifications of ‘multiply burdened’ group members, whose experiences are not captured in a single axis framework. Reference CrenshawCrenshaw (1989, 139) considered the position of black women in her analysis and showed how the perpetuation of the framework means they are systematically excluded in anti-discrimination law as well as feminist theory and anti-racist politics. The exclusion is aptly encapsulated in Gloria T. Hull’s edited book All the Women Are White, All the Blacks Are Brave, But Some of Us Are Brave (1982), which Reference CrenshawCrenshaw (1989, 139) took as a point of departure in her efforts to develop a black feminist critique. Writing in 1989, Crenshaw argued that the problem is that race and gender are treated as mutually exclusive categories of experience and analysis. This meant that in race politics, the black woman’s experiences of sexism are overlooked, and in gender politics the racism experienced by non-white women is overlooked. Intersectionality provides a framework for understanding how identity variables overlap with one another, creating different profiles of advantage and disadvantage that convey social relations and which show the very real differences between members within the group.
In the contemporary era, identities have becoming more complex and multi-layered because of processes of globalisation that have enabled an increase in travel, communication and contact. The term ‘transnational’ has been used since the 1990s to refer to a sense of identification that traverses national boundaries and encompasses multiple cultures and geographic locations. Reference AppaduraiArjun Appadurai (1990, 296) classifies global cultural flow in five dimensions, using the term ‘ethnoscape’ to describe the flow of people across boundaries (297). This creates more identity positions, making it possible to maintain strong connections to multiple places, or to be a part of multiple communities based on different lines, such as religion or language. The implications this has for migrant, diaspora populations will be explored in Chapter 2.
The Dismantling of the Term ‘BAME’
Collective identity categories such as BAME are double-edged. The benefits to society and public life include providing an organising category of certain minority groups that have been excluded, as a mechanism of gathering and collating statistics for the Office of National Statistics, for example, or for diversity monitoring in organisations. The more harmful consequences were seen during the Covid-19 pandemic. UK media campaigns targeted BAME groups as a whole. Whilst it is true that, relative to the majority white population, BAME groups are, as a whole, more adversely impacted by structural disadvantages (such as educational opportunities, employment and socio-economic background) the reports themselves acknowledged that some groups within the overarching category were more affected than others.
A nationwide poll by the British Red Cross to tackle vaccine hesitancy in early 2021 highlighted the huge variation in BAME groups between those who had or planned to have the vaccine and those who won’t take or aren’t sure about taking it.Footnote 14 The 85 per cent Indian and 89 per cent Chinese in the first category were close to or above the national average of 87 per cent as compared with the 46 per cent Black Caribbean, 31 per cent Black African or 25 per cent Pakistani, who were above the UK national average of 13 per cent. The findings highlight the dangers of treating BAME people as a homogeneous group in the matter of vaccine hesitancy. This example could be applied more widely to call for the need of more targeted campaigns as a better deployment of resources in the fight against Covid-19 and it raises the question whether lumping all groups together in such a way served to further disadvantage the more disadvantaged groups within the category of BAME.
Whilst the fervour of social injustice or inequality struggles associated with the BAME group identity may have benign intentions, the flattening of differences between non-white groups was harmful. In addition to the disadvantaging of specific groups within the broader category, it reinforced certain media stereotypes which, within the context of Covid-19, were that BAME groups were less informed about Covid-19, lived in housing with close proximity, were from low socio-economic backgrounds, and did not trust the establishment.
One of the recommendations in the final government report on Covid-19 disparities, published in December 2021, was to refer to ethnic minority groups individually, rather than as a single combined group (www.gov.uk/government/publications/final-report-on-progress-to-address-covid-19-health-inequalities). Building on this, in March 2021, the Commission on Race and Ethnic Disparities recommended the government stop using the term ‘BAME’. The report confirmed the need for a different and more precise way of thinking about diversity. The authors of this book concur about the limitations of the term ‘BAME’. Notwithstanding this, recommended alternatives to it, such as, ‘ethnic minorities (excluding white minorities)’Footnote 15 are problematic because of the emphasis on the exclusion of particular groups, rather than the collective classification of others. The claim is perhaps best illustrated by example. The assertion that BAME psychiatrists experience structural racism and marginalisation, for example, is not equivalent to stating that ethnic minority psychiatrists (excluding white minorities) experience this because the latter claim assumes that other white minorities do not share these experiences, which of course is false. This is highly problematic not least because it risks quashing the challenges that white ethnic minorities face, some of which may be similar to the issues experienced by BAME groups. This discussion highlights the limitations of grouping people together in these ways. Going forward, context will dictate how best to describe the group in question.
Strand 2: The Perspective of the South Asian Minority Psychiatrist in the UK
In the UK the place of South Asian doctors is particularly significant for several reasons. The movement of South Asian doctors to the UK has a unique history in that they were integral to the establishment of the NHS and continue to contribute in a substantial way to UK healthcare (see Chapter 2). Whilst one’s cultural identity is arguably relevant to greater or lesser extents in all branches of medicine, perhaps for different reasons it is fundamental within psychiatry. There are several aspects to the culture of South Asian psychiatrists that need to be considered, including their cultural identity and interactions with patients. The background knowledge South Asian psychiatrists possess is invaluable to understanding the cultural needs of South Asian patients. Furthermore, their life experiences of migration, racism and other forms of discrimination, and living with two or more very different cultures, may enhance their breadth of experience and give them insight into the critical life experiences of others. These multiple factors are explored in the narratives of the psychiatrists interviewed in this book. Capturing the voices of first-generation migrant South Asian psychiatrists who arrived in the immediate postwar decades has become a task of some urgency because many have now retired. Their recollections of working at a time before the mandating of cultural capability in clinical practice are useful both from an experiential and theoretical perspective.
First-generation South Asian psychiatrists have insights from their formative years of living and training in their country of origin, including local and folk traditions that may be informative and even therapeutic when treating patients from similar backgrounds. General Medical Council’s (hereafter GMC) records state that out of the total number of doctors registered with or without a licence to practice in 2022, 15.8 per cent of them had their primary medical qualification listed as being from one of the South Asian countries, specifically here Bangladesh, India, Nepal, Pakistan and Sri Lanka. This is a significant percentage of the workforce that have extensive experiences of indigenous cultural practices to draw upon.Footnote 16 Cultural psychiatry mandates that indigenous traditions need to be contextualised, which means that treatments that were once disregarded by Western-centric psychiatry, need to be recognised and evaluated ethnographically, in the culture from which they derive. And implicit in this viewpoint is that local traditions should not be seen as incompatible with ‘Western’ practices and may and often are used alongside each other (Reference Bhugra, Ranjith and PatelBhugra et al., 2005).Footnote 17 But even beyond specific and tangible bodies of knowledge, South Asian psychiatrists have a tacit understanding of the cultural groups of which they are a part, which means they understand the cultural habits and practices across South Asian groups to greater or lesser extents and will therefore have a deeper understanding of the explanatory models of South Asian patients. The de facto knowledge and experience possessed by South Asian psychiatrists should be recognised as important, which then raises the question of responsibility. If South Asian psychiatrists are the most qualified in their cultural understanding of South Asian populations, then should they shoulder the burden of representation whereby they are appointed spokespeople for patients from the same backgrounds? The response to this is not straightforward in that it is true that their views may carry more weight and be more informative, but this does not necessarily support making them institutionally responsible. Despite this, the power dynamic in the professional relationship needs to be recognised, which mars the relation between psychiatrist and patient.
In addition to the bodies of knowledge and insights that South Asian psychiatrists possess by virtue of their cultural identity and experiences, there is another type of knowledge that is generated, albeit unintentionally. Perhaps ‘exposing’ is a more accurate description of the way this knowledge comes to the fore. Notwithstanding the solid work of cultural psychiatry to advocate for a culturally sensitive approach and the manifold ways this has been and continues to be implemented, there is no getting around the fact that the institution of psychiatry remains white, in its legacies and in its link to power and privilege, which impacts on the South Asian psychiatrist in many ways. The whiteness is reflected in its organisational structures, namely its hierarchies and representation, and in the physical spaces of work and training, whether in the hospital or the academy. And whilst measures have been taken to mitigate this, which involve more drivers for equality, diversity and inclusion, such as the promotion of ethnic minority staff to senior grade posts, the white normativity of the institution has implications for the South Asian psychiatrist as non-white. The therapeutic relationship between psychiatrist and patient when the psychiatrist is from such a background may generate dynamics not seen if the psychiatrist is white. More than any other medical speciality, a clinical consultation with a psychiatrist requires the patient to be more open about their identity and other aspects of their being, including their mental and emotional states.Footnote 18 The cultural identity of the psychiatrist is not an irrelevant factor in considering the relationship with a patient even if the influence happens at a subconscious level. The literature on transference and counter-transference is vital here in addressing unconscious bias, or even more explicit prejudice (Reference Comas-Días and JacobsenComas-Díaz and Jacobsen, 1991).
Knowledge of the mental health of South Asian populations and broader contextual issues has thus far mainly been acquired through academic (including anthropological) and clinical research, some of which is authored by South Asian psychiatrists themselves (see Reference Bhugra and CochraneBhugra and Cochrane, 2001, for example). Handbook of Psychiatry: A South Asian Perspective comprises articles that are exclusively authored by South Asian psychiatrists from within and outside of the subcontinent (Reference Bhugra, Ranjith and PatelBhugra et al., 2005). In general, however, first-hand, subjective accounts within the field are sparse. Fernando’s monograph was pathbreaking for that reason. He was very open about drawing from his own experiences and observations ‘from within’ (as he put it; Reference FernandoFernando, 2017, 2). From his early days as a psychiatrist in the 1960s, where he was given his first opportunity to work with minority groups, the injustice he saw fuelled his activism and provided motivation for his determination for change.
Two recent studies of South Asian doctors, mainly general practitioners, both focusing on the UK context, are of merit primarily because of the emphasis they place on the views and words of the South Asian doctors themselves. Reference SimpsonJulian Simpson’s 2018 study and Reference FarooqYasmin Ghazala Farooq’s 2020 study examine the narratives of the experiences of the doctors, told in their own words. The use of the doctors’ own words in these two publications is significant. Being spoken for, however representationally, is not as centring an experience as having one’s own words used. Reference FarooqFarooq (2020, 28) commented on how the interviewees switched to communicate with her in South Asian languages, presumably mainly Urdu. She retained passages in Urdu (but also included translations) to convey the power of the thoughts and feelings of her subjects (10). These studies not only historicise the perspectives of the doctors but also personalise the narratives, making the injustices more tangible, and the need for change more urgent.
The Importance of the First-Person Narrative
This book foregrounds the lived experience of the South Asian psychiatrist. The lived experience, or phenomenology, examined more fully in Chapters 4 and 5, is a widely deployed method used in a number of domains including psychology, psychiatry, art, design, education and music, for example. Its popularity is attributed to the critical importance it places on the subject’s perceptual experiences, which promotes personalised solutions, helpful in a client-centred service industry. The relevance of phenomenology within psychiatry as a tool within therapy is patent. One only needs to consider ‘some of the central experiential categories that are afflicted in different psychopathological conditions, such as the structure of temporal and spatial experience, the demarcation between self and non-self, the experience of one’s own body, [and] the unity and identity of self’ to understand its appeal (Reference Zahavi and LoidoltZahavi and Loidolt, 2022). It leads to a more patient-centred approach and avoids the top-down imposition of external criteria onto the individual, thereby preventing reductionism (Reference Larsen, Maschião, Piedade, Messas and HastingsLarsen et al., 2022). Notwithstanding its clear benefits, it has implications for resources because it is time-consuming.
As a method in the context of exploring the South Asian psychiatrist’s perspective, the lived experience is important for several reasons. Of primary importance, highlighted in the Introduction, is the need to hear the perspectives of ethnic minority psychiatrists who have experiences and insights that will enrich the scholarship of cultural psychiatry. This includes their first-hand experiences of marginalisation that are invaluable in understanding concepts of mental health or wellbeing, including the notion of selfhood, ideas about belonging, feelings of displacement, challenges of fitting in, isolation and so on. Moreover, the GMC’s 2018–2020 equality, diversity and inclusion strategy states how the implementation of the strategy will enable ‘doctors [to be] 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 statement could be jarring for first-generation South Asian migrants who may have felt that their experiences were not valued. This sentiment would have especially been prevalent during the sea change in GMC policy in the late 1970s, which meant that qualifications from South Asian countries were no longer recognised (Reference SmithSmith, 1980, 11–12, cited in Reference SimpsonSimpson, 2018, 80).Footnote 19 Doctors had to undertake retraining of some kind in order to meet the requirements for registration. This indubitably created the perception that the prior experience in their home countries was of lesser value, and needed to be reformed to meet UK standards (Reference SimpsonSimpson, 2018, 80–81). Even for those arriving before the change in policy, having to adhere to different cultural practices may have been undermining and part of the long shadow cast by colonialism (see Reference EsmailEsmail, 2007, 827; Reference SimpsonSimpson, 2018, 94, 97).Footnote 20
Making central the South Asian psychiatrist’s voice in this book is an integral way of incorporating perspectives that have been overlooked and considering different epistemological frameworks, that is, wider bodies of knowledge and ways of knowing, informed by existential experiences of displacement in a multi-ethnic UK. Going forward, a few words about scope are needed. The book prioritises UK-based South Asian psychiatrists’ perspectives and claims made will be from this vantage point. The situation of finding oneself out of place or alienated because of differences (of whatever kind) is an experience shared by, though not exclusively, ethnic minority groups. Many of the ideas discussed within the context of the experience of South Asian psychiatrists in the book, particularly in Chapters 6 to 8, may be applicable to other ethnic minority psychiatrists and, even more widely, to health practitioners from those backgrounds. Though not explicitly stated, this should be understood. That being said, there are experiences that are also distinctive to the South Asian experience.
