Suman Fernando

Cultural diversity, mental health and psychiatry : the struggle against racism

Part 1: Background. Racism and cultural diversity. Responding to racism, addressing culture. Part 2: Underlying themes. Psychiatry and mental health from a transcultural perspective. Psychiatric stigma and racism. Part 3: Changing practice. Moving forward. Chapter 6.Future prospects. Summary

Multicultural Mental Health Services: Projects for Minority Ethnic Communities in England

Black and minority ethnic (BME) communities form 7.8% of the total population of the UK. Many of these communities face a variety of disadvantages when they access, or are forced to access, statutory mental health services under the National Health Service. Efforts have been made to address these problems by developing projects both within statutory mental health services and in the non-governmental (‘voluntary’) sector. This article describes some of these projects located in England, drawing out the themes and models that underlie their approaches, and discusses the lessons that can be learned from the U.K. experience.

Challenges in developing community mental health services in Sri Lanka

There are several issues to be faced in developing mental health services in South Asia if they are to be culturally and socially appropriate to the needs of the communities in the region. The meanings of mental health relevant to culturally appropriate service development can be obtained by exploring local notions of well-being, systems of care available to people and current practices among those seeking help for mental health problems. Participatory research carried out in communities in Sri Lanka affected by prolonged armed conflict and by the 2004 tsunami clarified the nature of well-being as perceived by communities themselves. Subsequent development of mental health services for Sri Lanka can be based on community consultation, using methodologies and interventions that involve the participation of the communities and their local institutions, and adapting relevant western approaches to the Sri Lankan context.

Services for People with Challenging Behaviour and Mental Health Needs at Risk of Offending

The closure of long‐stay hospitals and the emphasis on community living have highlighted the challenges services face in meeting the needs of some individuals. Government reports since 1990 on services for people with mental health needs, learning disabilities, challenging behaviour and/or criminal offending have recommended community living whenever possible, outlined the characteristics of good services and made suggestions about how these might be achieved (Department of Health, 1992; Department of Health, 1993; Royal College of Psychiatrists, 1996; NHS Executive, 1998). Nevertheless, most health and social service providers still find it difficult to attain the kinds of service proposed and Bouras (1999) recently concluded that this was partly a result of the separation of services for people with learning disabilities from mainstream mental health services. This paper reports the experience of a local service development intervention designed around the needs of this client group.

DSM‐5 and the ‘Psychosis Risk Syndrome’

The current system of diagnosis in psychiatry, whereby complex human problems are reduced to reified entities denoting medical illnesses located in the individual “mind”, is value‐laden and likely to be influenced by stereotypes and images of people held in society. The use of psychiatric diagnoses cross‐culturally is problematic. Black British people of African‐Caribbean ethnicity are over‐represented among people given the diagnosis schizophrenia/psychosis. This situation is explicable in terms of cultural misunderstanding coupled with institutional racism. Extending the diagnosis of schizophrenia/psychosis to children and young people by incorporating a category “psychosis risk syndrome” in DSM‐5 would have serious consequences for human rights.

Field Report: Perceptions of Social Stratification and Well‐being in Refugee Communities in North‐Western Sri Lanka

This paper reports findings of a study that was undertaken as a part of a wider programme of research and capacity building in Sri Lanka. The analysis of individual aspects of well‐being and how they had been affected by displacement provides a basis for the planning of interventions by helping agencies, and for training people who work with refugees.

Mental Health Services in Low-Income Countries: Challenges and Innovations

Mental health service provision varies enormously across the world and faces major challenges, largely determined by the contexts in which it functions. A variety of services exist side by side in low‐income countries. They include services provided in the statutory and private (fee‐paying) sectors, therapies provided by physicians working within indigenous systems of medicine, healing provided at religious locations and services provided by non‐governmental organisations. This paper provides a brief survey of some recent literature on mental health in low‐income countries and goes on to describe a few examples of innovative projects in these countries. The paper concludes by outlining some of the challenges faced by these countries in providing services in the modern world.

Book Review: Racism and Mental Health. Prejudice and Suffering

Over 30 years ago, in the preface to their book Racism and Psychiatry, Thomas and Sillen (1972) wrote ‘The extent of such involvement [in racist attitudes and practices] has come as a shock to most white psychiatrists, psychologists, social workers and other professionals’ (p. v). Since then, the reality of racism in the delivery of mental health services and psychiatric practice has become fairly common knowledge – at least in Britain, and especially among users of the mental health services. However, racism is seldom discussed openly in psychiatric and psychological academic circles and is rarely addressed in the training of psychiatrists and psychologists, even within courses on transcultural psychiatry. Meanwhile, the meaning of racism in a modern context has been written about extensively in the social sciences literature – for example, Racist Culture edited by David Goldberg (1993). Nevertheless, a few books do refer to racism in psychiatry and mental health systems – the two popular ones in Britain, Aliens and Alienists (Littlewood & Lipsedge, 1997) and Mental Health Race and Culture (Fernando, 2002), have kept going, with new editions since 1982 and 1992, respectively – and so a new book that attempts an overview of racism and mental health is extremely welcome. The aim of the book (to judge from the blurb on the back cover) is to bring together a variety of views on racism connected with: (i) its manifestation as suffering and prejudice felt by individuals, and (ii) clinical encounters and mental health service provision. Given the massive task undertaken, this book does well. Nine of the 14 chapters are written by Dr Bhui himself, four by other psychiatrists (jointly with Dr Bhui in one instance) and one chapter is by a black user of mental health services. This book is very much a British product referring to the British scene, except for one chapter about the US. Although not offering any original themes, the book contains a wealth of information and views drawn from a variety of books and

Mental Health for All

Mental health has many meanings and its maintenance is not just a medical problem but one that has religious, ethical and spiritual dimensions. While ideas about mental health are largely determined by culture, racism has distorted Western knowledge about other cultures and about people who are perceived as black, brown, red or yellow. But human beings the world over are not all that different in terms of their basic needs and as basic entities; it is the culturally determined ways of looking at human existence and the historically determined ways of judging people as distinct races that have imposed some (at least) of the problems arising from cultural and racial differences. Furthermore, people of different races and ethnic groups are increasingly having to interact with each other and to learn to live together. Racial antagonisms are counterproductive in terms of overall human progress and the isolated development of any one culture is no longer feasible. Yet racism is not dead and the adherence to ethnic identities appears to be growing in strength all over the world.

Race, Culture and Ethnicity

Ideas about race in European culture may be analysed by tracing the historical development of the concept of race (Banton, 1987). The term itself entered the English language in the sixteenth century at a time when the Bible was accepted as the authority on human affairs, and was used originally in the sense of lineage, supposedly ordained at the creation of the world. From then, well into the nineteenth century, race as lineage referred to groups of people connected by common descent or origin. Later, as Darwinian concepts were accepted in European thinking, race was seen as subspecies, and finally sociological theories of race led to the notion of races as populations. Today, all these ideas exist together, giving rise to considerable confusion in current thinking about race since the corollaries of these different notions are very different. For example, race as lineage explains why people are both physically and culturally different, but race as population does not do so very clearly; it may be a satisfactory explanation of physical differentiation of populations that are relatively isolated from each other, but cannot interpret cultural differentiation, except by assuming that ecological forces governing unconscious behaviour determines human culture in the way it determines social life of animals.