Swaran Singh: the social environment of immigrants explains their high rates of psychosis
Race is everywhere in British psychiatry. Responding to charges of institutional racism, politicians promise to make services more culturally sensitive. Black mental health groups argue for ethnically matched clinicians and special services for minorities. Yet, despite millions spent on equality initiatives, the number of black patients on psychiatric wards remains stubbornly high. Afro-Caribbeans are 44 per cent more likely than whites to be sectioned, 29 per cent more likely to be forcibly restrained, 50 per cent more likely to be placed in seclusion, and make up 30 per cent of inpatients on medium secure psychiatric wards.
To anti-racists this is a vivid illustration of the extent and entrenchment of institutional racism. In 2004, John Blofeld, a former high court judge, led an investigation into the death of black schizophrenic patient David Bennett at the Norvic clinic in 1998. Blofeld’s inquiry concluded that at the time, the mental health services were “a festering abscess” of institutional racism. Lee Jasper, ex-mayoral adviser to Ken Livingstone and former chair of the African Caribbean Mental Health Commission, said the inquiry proved the mental health service was like one in “an institutionally racist state.” He said: “Would you send your mother, if she were black, to a mental health institution? Not on these figures.”
Yet in clinical practice psychiatrists bend over backwards to be sensitive to the cultural needs of their patients—sometimes to the detriment of those patients. As a psychiatrist who has worked in the NHS for nearly 20 years, I have come across several cases where clinicians have subordinated their judgement to concerns about culture and race. I remember a severely unwell Nigerian woman whose delusions and hallucinations about witchcraft were accepted by her doctors as a cultural norm. I treated a Sikh woman who had become sexually and financially reckless in the early stages of manic depression. Her husband’s attempts to get help were dismissed as the cultural response of an Asian male unable to deal with female independence. Only after she was detained under the Mental Health Act did she get the proper help. But by the time she had recovered her marriage was over, her children were in care and her business was ruined.
Using data from a survey of community mental health teams, the King’s Fund reported in 2007 that black and white patients’ experiences of mental health care did not differ. In fact, black patients reported more positive experiences than their white counterparts. That same year, I co-published a systematic review pooling data from all British studies of detention under the Mental Health Act of ethnic minorities. We found no evidence that higher rates of detention were due to racism. Yet like most other clinicians, I have been confronted by many angry black patients and their families accusing services of being racist, misdiagnosing mental illness and forcibly medicating patients.
In 2006, I co-wrote a paper in the British Medical Journal emphasising that there were valid explanations other than racism for ethnic differences in mental health. Erroneous allegations drive a wedge of mistrust between ethnic minority patients and mental health services, creating a self-fulfilling prophecy whereby patients seek help only in a crisis, disengage from services prematurely and have repeated admissions with poor outcomes. One reason why ethnic minority patients are disproportionately detained is that they or their families are initially reluctant to accept treatment. But then a serious incident occurs, and doctors are required to use forcible means.
Our BMJ article was denounced by black mental health groups. In a public meeting I was called a “lone and eccentric voice” with whom no one agreed. This was partly correct. Very few people had dared to agree with me publicly, for to challenge any accusation of racism is to be seen as displaying racist tendencies. But in private, many colleagues sent emails of support.
I wrote the BMJ article partly because I had become increasingly worried about young black patients who refused to take medication out of mistrust. I was also concerned about the government’s demand in its 2005 action plan, “Delivering race equality in mental health care,” to reduce “disproportionate” admissions of black patients to psychiatric wards. Following this logic, an ill young black male could be denied admission if a ward required elderly white females to restore ethnic balance.
How did we get here? The debate has raged for two decades, ever since the first reports emerged of high rates of psychotic disorders and detention in ethnic minorities, particularly young black men. It was argued that psychiatrists were misdiagnosing mental illness in patients from other cultures, and treating them in a heavy-handed manner. Since then, several careful studies in different countries have shown that rates of serious mental illnesses are high in all migrant ethnic minorities, indicating that this is a function of migration rather than ethnicity. Researchers have used culturally neutral assessment scales devised by the WHO, rated the assessments blind to the ethnic origin of the patient, and even had psychiatrists from the Caribbean recheck the diagnoses. The findings stand.
Psychotic disorders—where sufferers lose touch with reality, experience hallucinations, develop delusions and behave irrationally—occur in all societies. Causal explanations may vary, from possession by spirits in one culture to stress in another. Culture plays a role—persecutory voices might be attributed to a goddess in rural India but to MI5 in Britain—but the occurrence of psychosis is not in doubt.
In 1932 Ornulv Odegaard, a Norwegian psychiatrist, reported an excess of schizophrenia in Norwegian migrants in Minnesota. Raised rates of psychosis in migrants has since been reported in several countries. The explanation lies in the social environment of immigrants. Recent research shows that social influences during early years are causally related to psychosis. Childhood exposure to economic adversity, family breakdown, social exclusion and living in areas with poor social cohesion all increase the risk. Ethnic minorities have higher rates of psychosis as they are much more likely to suffer these adversities.
It can be argued that greater experience of adversity is itself a manifestation of racism. This may be true, but it does not explain differences between, for example, Moroccan and Turkish immigrants in the Netherlands. Both groups have high rates of psychosis yet the rates in Moroccans are much higher. This possibly reflects that Turks migrated as families, with the protection that offers, while Moroccans migrated mainly as single men. Minority groups bring to the host society their own values and beliefs, family structure and community norms which can bolster resilience and reduce the impact of adversity. Consider the differences in educational achievement between Chinese and Afro-Caribbean boys and you see this complex interplay.
I arrived in Britain 20 years ago. On my third day here, a group of men assaulted me for “looking like Saddam Hussein.” A hospital consultant suggested that I should leave since there were too many of my kind here already. Such experiences fine-tune one’s antennae to racism. But I have yet to see evidence that overt, latent, institutional or any other kind of racism in psychiatry explains ethnic differences in psychosis.
As we become more diverse, extra attention to the cultural needs of minority groups is welcome. But too narrow a focus on cultural differences creates anxiety in clinicians, who worry about not causing affront. The result is that ethnic minorities remain inadequately treated as their care is reduced to an ideological battleground. The commonality of human suffering, pain and loss should allow us to understand the influences of culture without demanding that ethnic minority patients be treated in a different way. Such initiatives can never reduce ethnic disparities in mental health.
Racists and anti-racists are alike in one way—driven to view everyone through the distorting lens of race rather than as individuals. Differences in health are usually due to socioeconomic and cultural influences rather than skin colour. Just because there are racial differences does not mean that racism must be responsible.
Other articles in Prospect's special feature on the failings of multiculturalism today:
Tony Sewell on education
Lindsay Johns on dead white men
Sonya Dyer on the arts
Munira Mirza on her hometown of Oldham
Race is everywhere in British psychiatry. Responding to charges of institutional racism, politicians promise to make services more culturally sensitive. Black mental health groups argue for ethnically matched clinicians and special services for minorities. Yet, despite millions spent on equality initiatives, the number of black patients on psychiatric wards remains stubbornly high. Afro-Caribbeans are 44 per cent more likely than whites to be sectioned, 29 per cent more likely to be forcibly restrained, 50 per cent more likely to be placed in seclusion, and make up 30 per cent of inpatients on medium secure psychiatric wards.
To anti-racists this is a vivid illustration of the extent and entrenchment of institutional racism. In 2004, John Blofeld, a former high court judge, led an investigation into the death of black schizophrenic patient David Bennett at the Norvic clinic in 1998. Blofeld’s inquiry concluded that at the time, the mental health services were “a festering abscess” of institutional racism. Lee Jasper, ex-mayoral adviser to Ken Livingstone and former chair of the African Caribbean Mental Health Commission, said the inquiry proved the mental health service was like one in “an institutionally racist state.” He said: “Would you send your mother, if she were black, to a mental health institution? Not on these figures.”
Yet in clinical practice psychiatrists bend over backwards to be sensitive to the cultural needs of their patients—sometimes to the detriment of those patients. As a psychiatrist who has worked in the NHS for nearly 20 years, I have come across several cases where clinicians have subordinated their judgement to concerns about culture and race. I remember a severely unwell Nigerian woman whose delusions and hallucinations about witchcraft were accepted by her doctors as a cultural norm. I treated a Sikh woman who had become sexually and financially reckless in the early stages of manic depression. Her husband’s attempts to get help were dismissed as the cultural response of an Asian male unable to deal with female independence. Only after she was detained under the Mental Health Act did she get the proper help. But by the time she had recovered her marriage was over, her children were in care and her business was ruined.
Using data from a survey of community mental health teams, the King’s Fund reported in 2007 that black and white patients’ experiences of mental health care did not differ. In fact, black patients reported more positive experiences than their white counterparts. That same year, I co-published a systematic review pooling data from all British studies of detention under the Mental Health Act of ethnic minorities. We found no evidence that higher rates of detention were due to racism. Yet like most other clinicians, I have been confronted by many angry black patients and their families accusing services of being racist, misdiagnosing mental illness and forcibly medicating patients.
In 2006, I co-wrote a paper in the British Medical Journal emphasising that there were valid explanations other than racism for ethnic differences in mental health. Erroneous allegations drive a wedge of mistrust between ethnic minority patients and mental health services, creating a self-fulfilling prophecy whereby patients seek help only in a crisis, disengage from services prematurely and have repeated admissions with poor outcomes. One reason why ethnic minority patients are disproportionately detained is that they or their families are initially reluctant to accept treatment. But then a serious incident occurs, and doctors are required to use forcible means.
Our BMJ article was denounced by black mental health groups. In a public meeting I was called a “lone and eccentric voice” with whom no one agreed. This was partly correct. Very few people had dared to agree with me publicly, for to challenge any accusation of racism is to be seen as displaying racist tendencies. But in private, many colleagues sent emails of support.
I wrote the BMJ article partly because I had become increasingly worried about young black patients who refused to take medication out of mistrust. I was also concerned about the government’s demand in its 2005 action plan, “Delivering race equality in mental health care,” to reduce “disproportionate” admissions of black patients to psychiatric wards. Following this logic, an ill young black male could be denied admission if a ward required elderly white females to restore ethnic balance.
How did we get here? The debate has raged for two decades, ever since the first reports emerged of high rates of psychotic disorders and detention in ethnic minorities, particularly young black men. It was argued that psychiatrists were misdiagnosing mental illness in patients from other cultures, and treating them in a heavy-handed manner. Since then, several careful studies in different countries have shown that rates of serious mental illnesses are high in all migrant ethnic minorities, indicating that this is a function of migration rather than ethnicity. Researchers have used culturally neutral assessment scales devised by the WHO, rated the assessments blind to the ethnic origin of the patient, and even had psychiatrists from the Caribbean recheck the diagnoses. The findings stand.
Psychotic disorders—where sufferers lose touch with reality, experience hallucinations, develop delusions and behave irrationally—occur in all societies. Causal explanations may vary, from possession by spirits in one culture to stress in another. Culture plays a role—persecutory voices might be attributed to a goddess in rural India but to MI5 in Britain—but the occurrence of psychosis is not in doubt.
In 1932 Ornulv Odegaard, a Norwegian psychiatrist, reported an excess of schizophrenia in Norwegian migrants in Minnesota. Raised rates of psychosis in migrants has since been reported in several countries. The explanation lies in the social environment of immigrants. Recent research shows that social influences during early years are causally related to psychosis. Childhood exposure to economic adversity, family breakdown, social exclusion and living in areas with poor social cohesion all increase the risk. Ethnic minorities have higher rates of psychosis as they are much more likely to suffer these adversities.
It can be argued that greater experience of adversity is itself a manifestation of racism. This may be true, but it does not explain differences between, for example, Moroccan and Turkish immigrants in the Netherlands. Both groups have high rates of psychosis yet the rates in Moroccans are much higher. This possibly reflects that Turks migrated as families, with the protection that offers, while Moroccans migrated mainly as single men. Minority groups bring to the host society their own values and beliefs, family structure and community norms which can bolster resilience and reduce the impact of adversity. Consider the differences in educational achievement between Chinese and Afro-Caribbean boys and you see this complex interplay.
I arrived in Britain 20 years ago. On my third day here, a group of men assaulted me for “looking like Saddam Hussein.” A hospital consultant suggested that I should leave since there were too many of my kind here already. Such experiences fine-tune one’s antennae to racism. But I have yet to see evidence that overt, latent, institutional or any other kind of racism in psychiatry explains ethnic differences in psychosis.
As we become more diverse, extra attention to the cultural needs of minority groups is welcome. But too narrow a focus on cultural differences creates anxiety in clinicians, who worry about not causing affront. The result is that ethnic minorities remain inadequately treated as their care is reduced to an ideological battleground. The commonality of human suffering, pain and loss should allow us to understand the influences of culture without demanding that ethnic minority patients be treated in a different way. Such initiatives can never reduce ethnic disparities in mental health.
Racists and anti-racists are alike in one way—driven to view everyone through the distorting lens of race rather than as individuals. Differences in health are usually due to socioeconomic and cultural influences rather than skin colour. Just because there are racial differences does not mean that racism must be responsible.
Other articles in Prospect's special feature on the failings of multiculturalism today:
Tony Sewell on education
Lindsay Johns on dead white men
Sonya Dyer on the arts
Munira Mirza on her hometown of Oldham
