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ETHNIC ISSUES IN UK. Black / Ethnic Minorities more often:Diagnosed as schizophrenicCompulsorily detained under M.H.ActAdmitted as
RACE AND CULTURE ISSUES IN MENTAL HEALTH THOUGHTS ON IDEN...

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1. ?RACE? AND CULTURE ISSUES IN MENTAL HEALTH & THOUGHTS ON IDENTITY Suman Fernando www.sumanfernando.com European Centre for Migration & Social Care (MASC), University of Kent Department of Applied Social Studies London Metropolitan University There are two sections to my talk, the first addressing the overall topic for today and the second referring back to yesterday, when we had all those wonderful talks. ? Mental Health, Race and Culture Issues around race and culture in mental health services in the UK have been highlighted in the literature since the early 1980s ? the main concerns being around admission to psychiatric institutes and compulsory detention (?sectioning?) under the Mental Health Act (e.g. see McGovern and Cope, 1987; Moodley and Thornicroft, 1988; Coid et al. 2000) and the diagnosis of schizophrenia. The main thrust of these issues is well known (Fernando, 1988, 2003). There are two sections to my talk, the first addressing the overall topic for today and the second referring back to yesterday, when we had all those wonderful talks. ? Mental Health, Race and Culture Issues around race and culture in mental health services in the UK have been highlighted in the literature since the early 1980s ? the main concerns being around admission to psychiatric institutes and compulsory detention (?sectioning?) under the Mental Health Act (e.g. see McGovern and Cope, 1987; Moodley and Thornicroft, 1988; Coid et al. 2000) and the diagnosis of schizophrenia. The main thrust of these issues is well known (Fernando, 1988, 2003).

2. ETHNIC ISSUES IN UK Black / Ethnic Minorities more often: Diagnosed as schizophrenic Compulsorily detained under M.H.Act Admitted as ?Offender Patients? Held by police under S. 136 of M.H.Act Transferred to locked wards Not referred for ?talking therapies? Given high doses of medication Sent to psychiatrists by courts Ref: Fernando, S. (2009) ?Inequalities and the politics of race in mental health?, in S. Fernando and F. Keating , Mental Health in a Multi-ethnic Society second edition, Routledge, London and New York Slide: Ethnic issues in UK ? But these problems are not confined to psychiatry. Counselling services and psychology services too have them - more hidden than in psychiatry ? and certainly getting less publicity mainly I think because they do not have the same obvious power for example in not having legal powers to force treatment. But the problems are there. Detailed ethnic statistics on counselling and psychotherapy (for example on what clients actually think about them) are few and far between. However, we know that (in the US at any rate) there are high drop out rates (Rosenthal and Frank, 1958) and low acceptance rates (Yamamoto et al. 1968) of black clients, the latter recorded as being to do with ?ethnocentricity? of the therapists (Yamamoto et al. 1967) ? which could as easily be called unconscious racism. In the late 1980s a trainee in Leicester (UK) wrote in to the Psychiatric Bulletin saying that while in the acute ward of her hospital she encountered many black patients in the psychotherapy unit there were none (Campling, 1989). I initiated one of the early ethnic monitoring exercises in the psychiatric unit I was working at to find very similar figures. [circulated the figures but fell on deaf ears.] ? I have presented statistics from UK because I am familiar with these but also because in the UK we seem to collect a lot of ethnic statistics. Many other European countries do not collect these statistics and I do not think Ontario does either. Anecdotal information suggests that, if anything, the inequities may be much worse in mainland Europe than they are in UK ? and perhaps the same may apply to North America too. A recent book from the USA, Protest Psychosis; How Schizophrenia became a Black Disease by Jonathan Metzl (2009) shows how in the USA, fears of black militancy in the 1960s, together with radical shifts in diagnostic habits codified in DSM, converged to construct a situation where the use of schizophrenia diagnosis for African Americans came into play on a large scale during the civil rights movement (essentially for social control) ? and this over-representation of African-Americans as ?schizophrenics? continues. ? Coming back to psychiatric studies, there have been many epidemiological studies around the issues of ?sectioning? (i.e. compulsory admission to treatment) and of schizophrenia ? talked about as ?the problem of over-representation?. And there has been quite a lot written about the reasons for all this - not least by me - but, politically speaking, we have not got very far in enabling this written work (?research? one could call it) to be taken seriously enough to bring about change, to make things more equitable ? ?race? equality? is the term used. Or it may be that the sort of change that should be made is just not acceptable politically and socially ? and I dare say professionally probably because it is felt as striking at professional competence. [There talk of course about cultural sensitivity and even ?cultural formulation? approach of US is copied in UK.] ? On the other hand there have been some high profile deaths (and many low profile ones) in psychiatric custody of black people, the latest high profile one being that of Rocky Bennett (Norfolk, Suffolk and Cambridgeshire Strategic Health Authority, 2003). [Norfolk quarrel with white patient ? transferred to locked ward ? attacked a nurse ?why me? ? held down by 6-8 nurses ? died of suffocation.} ? It we turn to what service users make of this (he experience of people who use mental health services) a recent report sums it up (Keating et al. 2003).Slide: Ethnic issues in UK ? But these problems are not confined to psychiatry. Counselling services and psychology services too have them - more hidden than in psychiatry ? and certainly getting less publicity mainly I think because they do not have the same obvious power for example in not having legal powers to force treatment. But the problems are there. Detailed ethnic statistics on counselling and psychotherapy (for example on what clients actually think about them) are few and far between. However, we know that (in the US at any rate) there are high drop out rates (Rosenthal and Frank, 1958) and low acceptance rates (Yamamoto et al. 1968) of black clients, the latter recorded as being to do with ?ethnocentricity? of the therapists (Yamamoto et al. 1967) ? which could as easily be called unconscious racism. In the late 1980s a trainee in Leicester (UK) wrote in to the Psychiatric Bulletin saying that while in the acute ward of her hospital she encountered many black patients in the psychotherapy unit there were none (Campling, 1989). I initiated one of the early ethnic monitoring exercises in the psychiatric unit I was working at to find very similar figures. [circulated the figures but fell on deaf ears.] ? I have presented statistics from UK because I am familiar with these but also because in the UK we seem to collect a lot of ethnic statistics. Many other European countries do not collect these statistics and I do not think Ontario does either. Anecdotal information suggests that, if anything, the inequities may be much worse in mainland Europe than they are in UK ? and perhaps the same may apply to North America too. A recent book from the USA, Protest Psychosis; How Schizophrenia became a Black Disease by Jonathan Metzl (2009) shows how in the USA, fears of black militancy in the 1960s, together with radical shifts in diagnostic habits codified in DSM, converged to construct a situation where the use of schizophrenia diagnosis for African Americans came into play on a large scale during the civil rights movement (essentially for social control) ? and this over-representation of African-Americans as ?schizophrenics? continues. ? Coming back to psychiatric studies, there have been many epidemiological studies around the issues of ?sectioning? (i.e. compulsory admission to treatment) and of schizophrenia ? talked about as ?the problem of over-representation?. And there has been quite a lot written about the reasons for all this - not least by me - but, politically speaking, we have not got very far in enabling this written work (?research? one could call it) to be taken seriously enough to bring about change, to make things more equitable ? ?race? equality? is the term used. Or it may be that the sort of change that should be made is just not acceptable politically and socially ? and I dare say professionally probably because it is felt as striking at professional competence. [There talk of course about cultural sensitivity and even ?cultural formulation? approach of US is copied in UK.] ? On the other hand there have been some high profile deaths (and many low profile ones) in psychiatric custody of black people, the latest high profile one being that of Rocky Bennett (Norfolk, Suffolk and Cambridgeshire Strategic Health Authority, 2003). [Norfolk quarrel with white patient ? transferred to locked ward ? attacked a nurse ?why me? ? held down by 6-8 nurses ? died of suffocation.} ? It we turn to what service users make of this (he experience of people who use mental health services) a recent report sums it up (Keating et al. 2003).

3. ?CIRCLES OF FEAR? REPORT 2003 SERVICES Too coercive, lack respect, and not integrated with community PATHWAYS Do not involve primary care and community based facilities DISCOURSE Models of ?mental illness? do not acknowledge cultural diversity SERVICE USER AND CARER INVOLVMENT Poor or non-existent BLACK-LED INITIATIVES Not valued or supported properly Ref. Keating et al., (2003) Breaking the Circles of Fear. A Review of the relationship between mental health services and African and Caribbean communities. (London: Sainsbury Centre for Mental Health). Slide: Circles of fear report ? Today, in UK there is an acceptance of serious problems, but little headway in getting any change. In an effort to understand what is going on, my approach over the years has been to first ask the question how we have got here. What the lay of the land may be, the background to all this, the broader scene. For one thing the race statistics in mental health services resemble, not statistics in other parts of health but resemble those of (a) disproportionate exclusion from school of black boys (for difficult behaviour) and (b) black over-representation in prisons (summarised by Fernando, 2009). In fact, although ?culture? may well be involved at some level in mental health field ? as may be social class and poverty - it seems mostly a ?race? issue. ? What I shall do in this talk, is to summarise briefly something of what I have written and spoken about for some years and then try to draw some conclusions. Slide: Circles of fear report ? Today, in UK there is an acceptance of serious problems, but little headway in getting any change. In an effort to understand what is going on, my approach over the years has been to first ask the question how we have got here. What the lay of the land may be, the background to all this, the broader scene. For one thing the race statistics in mental health services resemble, not statistics in other parts of health but resemble those of (a) disproportionate exclusion from school of black boys (for difficult behaviour) and (b) black over-representation in prisons (summarised by Fernando, 2009). In fact, although ?culture? may well be involved at some level in mental health field ? as may be social class and poverty - it seems mostly a ?race? issue. ? What I shall do in this talk, is to summarise briefly something of what I have written and spoken about for some years and then try to draw some conclusions.

4. Slide: Historical context of psychiatry ? Psychiatry arose in post-enlightenment Europe, about 200 - 300 years ago, from two main sources. First the need to control and put away so-called ?lunatics? who were disturbing, one way or the other, social order in European cities; and second, from a growing interest in matters to do with the ?mind? in European medical circles. So containment of criminality (or social control) and the medical approach towards understanding lunacy came together. And, as groups of problems, mental states and behaviours became classified as ?illnesses?, modern psychiatry came into being as a medical discipline but one that carries within it a strong element of social control (see Fernando, 2010). That is a very potted history to start with. ? Now the situation in non-western cultural traditions of (say) Asia, Africa and pre-Columbian America is very different, but (and an important but) during colonialism and even more so as a part of more recent ?globalisation? western beliefs about (what we call) mental heath and illness and ways of controlling the latter have been imposed and / or taken up across most of the world. Yet, in more subtle ways, there is a movement the other way too (from East to West as it were). So the interactions are complex, but, when we add in the dimensions of power and economics the movement is predominantly one way (see the popular book Crazy Like Us by Ethan Watters, 2010). The reality however is that there are indeed different traditions that we can draw on to create perhaps hybrids, sort of fusions may be ? multicultural systems - that suit particular age and place, depending on context. But, power and economics (e.g. Big Pharma) comes in. Although generalisations could be misleading, let me indicate roughly where differences in approach may lie by considering different ideals of mental health. Slide: Historical context of psychiatry ? Psychiatry arose in post-enlightenment Europe, about 200 - 300 years ago, from two main sources. First the need to control and put away so-called ?lunatics? who were disturbing, one way or the other, social order in European cities; and second, from a growing interest in matters to do with the ?mind? in European medical circles. So containment of criminality (or social control) and the medical approach towards understanding lunacy came together. And, as groups of problems, mental states and behaviours became classified as ?illnesses?, modern psychiatry came into being as a medical discipline but one that carries within it a strong element of social control (see Fernando, 2010). That is a very potted history to start with. ? Now the situation in non-western cultural traditions of (say) Asia, Africa and pre-Columbian America is very different, but (and an important but) during colonialism and even more so as a part of more recent ?globalisation? western beliefs about (what we call) mental heath and illness and ways of controlling the latter have been imposed and / or taken up across most of the world. Yet, in more subtle ways, there is a movement the other way too (from East to West as it were). So the interactions are complex, but, when we add in the dimensions of power and economics the movement is predominantly one way (see the popular book Crazy Like Us by Ethan Watters, 2010). The reality however is that there are indeed different traditions that we can draw on to create perhaps hybrids, sort of fusions may be ? multicultural systems - that suit particular age and place, depending on context. But, power and economics (e.g. Big Pharma) comes in. Although generalisations could be misleading, let me indicate roughly where differences in approach may lie by considering different ideals of mental health.

5. ?EASTERN? HARMONY WITH OTHER PEOPLE ?OTHER-ESTEEM? VALUED RELATIONSHIPS BALANCE (?ecological?) KEEP OUTER WORLD CONSTANT CONFORMITY WITH SOCIETY FREEDOM OF INNER EXPERIENCE VARIETY OF INNER EXPERIENCE ?WESTERN? INDIVIDUAL (SELF) SUFFICIENCY ?SELF-ESTEEM? VALUED PERSONAL AUTONOMY EFFICIENCY (?machine-like?) KEEP INNER WORLD CONSTANT CONTROL ALTERED STATES OF C-NESS FREEDOM OF EXPRESSION VARIETY IN BEHAVIOUR Slide: Ideals of Mental Health ? In general, non-western (?Eastern?) traditions of mental health (as compared to the western that underpins much of psychiatry and western psychology) these emphasise balance, harmony and stability of outer world of relationships (see Kakar, 1982: Fernando, 2010). The biggest difference may well centre on individualism ? and this may well be a source of difficulty in counselling. For instance, Professor Hwang (2000) of the counselling service at San Diego writes that, in counselling people in a multicultural society, other-esteem (respect for other people) may be more important than self-esteem for a meaningful life in a multicultural society. ? As I said earlier, psychiatry and psychology arose in the context of the European Enlightenment (of the 17-18th century) when ideas of freedom of the individual and dignity of man (and later woman), developed. But something often forgotten is that, at the time of this ?Enlightenment?, white-on-black slavery was at its peak. Some writers on the Enlightenment dismiss this as a paradox (e.g. Outram, 2005) ? just one of those things; but to Toni Morrison (1993) (Playing in the Dark. Whiteness and the Literary Imagination) this fact is very significant. We can see now that racism was embedded in post-enlightenment values. Major Enlightenment figures, like Hume, Kant and Hegel, articulated unchallenged extreme racist ideas (Eze, 1997). Anti-Semitism, the Atlantic slave trade, colonialism and scientific racism, all flourished well after the ideas of freedom and dignity of the individual became so-called ?European values?. Just as racism is the key ? or one of the keys - to understanding how this happened, it may well be that racism is a key to understanding the apparent paradox we see in the mental health scene today ? the fact of black people?s negative experience of a supposedly caring, medical profession like psychiatry, and the problems we seem to have in developing culturally sensitive ways of practising psychological therapies. [Although much of the writing is about ?culture? if we dig a bit below this surface we find that it is ?race? that really matters. A big problem I believe I tacking this is our tendency toe conflate the two concepts ? race and culture. Slide: Ideals of Mental Health ? In general, non-western (?Eastern?) traditions of mental health (as compared to the western that underpins much of psychiatry and western psychology) these emphasise balance, harmony and stability of outer world of relationships (see Kakar, 1982: Fernando, 2010). The biggest difference may well centre on individualism ? and this may well be a source of difficulty in counselling. For instance, Professor Hwang (2000) of the counselling service at San Diego writes that, in counselling people in a multicultural society, other-esteem (respect for other people) may be more important than self-esteem for a meaningful life in a multicultural society. ? As I said earlier, psychiatry and psychology arose in the context of the European Enlightenment (of the 17-18th century) when ideas of freedom of the individual and dignity of man (and later woman), developed. But something often forgotten is that, at the time of this ?Enlightenment?, white-on-black slavery was at its peak. Some writers on the Enlightenment dismiss this as a paradox (e.g. Outram, 2005) ? just one of those things; but to Toni Morrison (1993) (Playing in the Dark. Whiteness and the Literary Imagination) this fact is very significant. We can see now that racism was embedded in post-enlightenment values. Major Enlightenment figures, like Hume, Kant and Hegel, articulated unchallenged extreme racist ideas (Eze, 1997). Anti-Semitism, the Atlantic slave trade, colonialism and scientific racism, all flourished well after the ideas of freedom and dignity of the individual became so-called ?European values?. Just as racism is the key ? or one of the keys - to understanding how this happened, it may well be that racism is a key to understanding the apparent paradox we see in the mental health scene today ? the fact of black people?s negative experience of a supposedly caring, medical profession like psychiatry, and the problems we seem to have in developing culturally sensitive ways of practising psychological therapies. [Although much of the writing is about ?culture? if we dig a bit below this surface we find that it is ?race? that really matters. A big problem I believe I tacking this is our tendency toe conflate the two concepts ? race and culture.

6. Slide: Historical context of psychiatry ? In the 19th and first part of the 20th century, racist theories were integral to what went for psychiatric knowledge and indeed for knowledge about people in general ? and of course race-thinking was deeply embedded in much of psychology ? for example this was obvious in the eugenic movement. ? Since the 1939-45 war, racism has been rejected in scientific circles and latterly in most civilised discourse in all professions, but subtle forms of racism and what we call ?institutional racism? are far from extinct. I shall go over the next few sides fairly quickly. Slide: Historical context of psychiatry ? In the 19th and first part of the 20th century, racist theories were integral to what went for psychiatric knowledge and indeed for knowledge about people in general ? and of course race-thinking was deeply embedded in much of psychology ? for example this was obvious in the eugenic movement. ? Since the 1939-45 war, racism has been rejected in scientific circles and latterly in most civilised discourse in all professions, but subtle forms of racism and what we call ?institutional racism? are far from extinct. I shall go over the next few sides fairly quickly.

7. RACIST DISCOURSE IN 19th C Do black people have higher rates of ?insanity? (when compared to white people)? ------ 1. (White) civilisation causes insanity So ?noble savage? is free of insanity Supported by Tuke, 1858; Maudsley, 1867; Esquirol (Jarvis, 1852) 2. ?Savages? are mentally degenerate anyway (quoted by AubreyLewis, 1965) 3. Insanity levels (in US) among Blacks: Low when in slavery; High when set free (Anon, 1851)

8. Models of psychiatric pathology 19th Century influences ?Degeneration? (Morel, 1852) ?Born criminal? (Lombroso, 1871) Dementia praecox (schizophrenia) (Kraepelin, 1896; Bleuler, 1911) [?Depression? as melancholia goes back to Hippocrates] References Kraepelin, E. (1896) Psychiatrie, 5th Edition. (Leipzig: Barth) Bleuler, E. (1911) Dementia Praecox or the Group of Schizophrenias. Trans. J. Zitkin (New York: International Universities Press; repr. 1950) Morel, B. A. (1852) Traites des Mentales (Paris: Masson) Pick, D. (1989) Faces of Degeneration.: a European Disorder c. 1848-c.1918. (Cambridge: Cambridge University Press) Fernando, S., Ndegwa, D. & Wilson, M. (1998) Forensic Psychiatry, Race and Culture. (London; Routledge) Fernando, S. (2003) Cultural Diversity, Mental Health and Psychiatry. The struggle against racism. (Hove and New York: Brunner-Routledge) Lombroso, C. (1871) White man and the coloured man; Observations on the origin and variety of the human race, Padua Lombroso, C. (1911) Crime its causes and remedies, trans. H. P. Horton, London: Hennemann.

9. RACIST THEORIES IN PSYCHIATRY & PSYCHOLOGY ?Idiots and ?imbeciles? suffer from ?racial throwback? (degeneration) to Ethiopian, Malay, American and Mongolian racial types (John Langdon Down, 1866) Indians, Africans and North American Aborigines are ?adolescent races? equivalent to children of white races (Stanley Hall, 1904) Javanese do not get depressed or suffer from guilt ? ?psychically under-developed? (Kraepelin, 1921) Psyche of (white) Americans liable to be pulled down by racial infection? of living too close to primitive black people (Jung, 1930) Slide: Racist theories in psychology and psychology ? In spite of the demise of scientific racism after the second European war, colour-based racist discourse within psychiatry went largely unchallenged well into the 1960s. Slide: Racist theories in psychology and psychology ? In spite of the demise of scientific racism after the second European war, colour-based racist discourse within psychiatry went largely unchallenged well into the 1960s.

10. RACIST DISCOURSE IN MODERN TIMES (examples) Africans did not get depressed because they lacked ?sense of responsibility? and their thinking resembled that of ?leucotomised Europeans? (Carothers, 1951) Asians, Africans and African-Americans show less developed ?emotional differentiation? (Leff, 1973, 1977) Racist IQ movement (Jensen, 1969) supported by Eysenck (1971,1973) Repeated by Herrnstein & Murray (1994) and Rushton (1997) Also note Depression became commoner in Africans after Ghana became independent (Prince, 1968) ?Schizophrenics? have better outcome in under-developed countries (WHO, 1979) High rates of schizophrenia diagnosis among Blacks in US, UK, Netherlands (see Fernando, 2003), ?Canada Slide: Racist discourse in modern times ? Then in the 1970s and 1980s, as Britain became significantly mixed racially ? it had always been mixed culturally as a result of waves of immigration mainly from other parts of Europe ? as racial differences became significantly obvious in its population, racial and cultural issues in the mental health system were highlighted. Slide: Racist discourse in modern times ? Then in the 1970s and 1980s, as Britain became significantly mixed racially ? it had always been mixed culturally as a result of waves of immigration mainly from other parts of Europe ? as racial differences became significantly obvious in its population, racial and cultural issues in the mental health system were highlighted.

11. ETHNIC ISSUES IN UK Black / Ethnic Minorities more often: Diagnosed as schizophrenic Compulsorily detained under M.H.Act Admitted as ?Offender Patients? Held by police under S. 136 of M.H.Act Transferred to locked wards Not referred for ?talking therapies? Given high doses of medication Sent to psychiatrists by courts Ref: Fernando, S. (2009) ?Inequalities and the politics of race in mental health?, in S. Fernando and F. Keating , Mental Health in a Multi-ethnic Society second edition, Routledge, London and New York Slide: Ethnic Issues ? In trying to explore the issues depicted here the main approach in psychiatric research ? again mostly done in UK ? the main approach has been epidemiological, i.e. to analyze what is called the high ?incidence? of schizophrenia ? or sectioning - among black people and to do so without questioning the process of diagnosis or indeed sectioning. There have been a few attempts however to actually look at this process. One striking study was by Loring and Powell (1988) in the US. What they did was to circulate 290 psychiatrists with carefully constructed vignettes, sometimes giving gender and race, asking them various detailed questions while concealing the real purpose of their study. What they found was that (a) overall, black clients, compared to white clients, were given a diagnosis of schizophrenia more frequently by both black and white clinicians (although done to a lesser extent by the former); and (b) all the clinicians appeared to ascribe violence, suspiciousness and dangerousness to black clients even though the case studies were the same as those for the white clients. Their conclusion was that black and white patients ?seen differentially even if they exhibit the same behaviour? and that these differences get legitimized in official statistics? (1988: 19). [A less sophisticated and smaller study in UK done by Lewis et al. (1990) did not produce such conclusions. I did a critique (Fernando, 1991) of the subtleties that may have determined this negative finding. The one vignette used did not mention race of the person directly but gave a description that had many signals at that time ? such as train driver on London transport.] ? In my view in describing statistics we should really talk of high rates of diagnosis not ?high incidence?. And when we examine statistics of diagnoses, we would at the same time consider how the diagnoses are made. If we study drop out rates from counseling we should at the same time study processes involved including honest appraisals by users of the service. I would call this research in a critical mode, rather than a traditional medical-type one where diagnosis and professional assessments are something ?given?. Slide: Ethnic Issues ? In trying to explore the issues depicted here the main approach in psychiatric research ? again mostly done in UK ? the main approach has been epidemiological, i.e. to analyze what is called the high ?incidence? of schizophrenia ? or sectioning - among black people and to do so without questioning the process of diagnosis or indeed sectioning. There have been a few attempts however to actually look at this process. One striking study was by Loring and Powell (1988) in the US. What they did was to circulate 290 psychiatrists with carefully constructed vignettes, sometimes giving gender and race, asking them various detailed questions while concealing the real purpose of their study. What they found was that (a) overall, black clients, compared to white clients, were given a diagnosis of schizophrenia more frequently by both black and white clinicians (although done to a lesser extent by the former); and (b) all the clinicians appeared to ascribe violence, suspiciousness and dangerousness to black clients even though the case studies were the same as those for the white clients. Their conclusion was that black and white patients ?seen differentially even if they exhibit the same behaviour? and that these differences get legitimized in official statistics? (1988: 19). [A less sophisticated and smaller study in UK done by Lewis et al. (1990) did not produce such conclusions. I did a critique (Fernando, 1991) of the subtleties that may have determined this negative finding. The one vignette used did not mention race of the person directly but gave a description that had many signals at that time ? such as train driver on London transport.] ? In my view in describing statistics we should really talk of high rates of diagnosis not ?high incidence?. And when we examine statistics of diagnoses, we would at the same time consider how the diagnoses are made. If we study drop out rates from counseling we should at the same time study processes involved including honest appraisals by users of the service. I would call this research in a critical mode, rather than a traditional medical-type one where diagnosis and professional assessments are something ?given?.

12. PSYCHIATRIC DIAGNOSES Not objective facts but hypotheses that may or may not be useful Distinction between ?mental? and most physical illnesses Usefulness rather than validity is what matters in mental health matters Refs: Kendell, R. E. (2001) ?The distinction between mental and physical illness.? British Journal of Psychiatry, 178, 490-493. [http://bjp.rcpsych.org/vol178/issue6] Kendell, R. & Jablensky, A. (2003) ?Distinguishing between the validity and utility of psychiatric diagnoses.? American Journal of Psychiatry, 160, 4-12 [abstract http://ajp.psychiatryonline.org/cgi/content/abstract/160/1/4] Slide: Diagnosis ? In one of his last papers (co-authored with Jablensky) Bob Kendell, one-time president of the Royal College of Psychiatrists, stated that ?diagnostic categories are simply concepts, justified only by whether they provide a useful framework for organizing and explaining the complexity of clinical experience in order to derive inferences about outcome and to guide decisions about treatment? (Kendell and Jablensky, 2003: 5). The paper warned against reifying a diagnosis by assuming that it is ?an entity of some kind that can be evoked to explain the patient?s symptoms and whose validity need not be questioned? (2003: 5). The same may be said about making assessments for counselling or psychotherapy, by say the intake team of a service. The tendency to accept as correct ? even to reify - the findings of an assessment, that for example the client is too enmeshed in his family or ( a very common diagnosis one time for young black people) has a problem with authority. If you look closely, you may find this is more a reflection of how the assessor draws from his or her (possibly ethnocentric) training about how people should separate from ?family? or the client?s place in society as anything else. ? So in societies where people come from diverse cultural backgrounds, psychiatric diagnoses and ways of assessment (evolved in ?western? culture), if they are to be useful, have to address the fact not just of diversity in how health and illness are understood for example ? but also the judgments about good and bad cultures that we may carry. [extreme example, in Hungary Roma child ?rescued from bad influence.] So perhaps not surprisingly, psychiatric research tied to diagnosis as it is.has produced very little that we can act on ? except perhaps some evidence that racism in society may cause illness through social stress (McKenzie, 2003) or that the explanations may lie in differing pathways into care (e.g. Bhui et al. 2003; Morgan et al. 2005). ? [This lack of progress in ethnic studies has been called (Eaton and Harris, 2000) ?circular epidemiology? (Kuller, 1999) ? a rut in which researchers are in because they refuse to question the dogma of traditional ways of diagnosis and assessment (Fernando, 2003)] ? Recently we saw a dangerous situation arising from social determinants-type research that is popular just now in Britain (and perhaps in Canada too) when done in a medical framework, ? or should I say in a narrow medical framework. The work came from (in fact a very expensive) study from the Institute of Psychiatry (Morgan and Hutchinson, 2010). A national newspaper (the Guardian) in December 2010 quoted that the researchers would back the lead for mental health at government level (the person we call the ?psychiatric tsar?) for a ?program of social engineering? of black family life in order to save black children from becoming ?schizophrenic? (Lewin, 2009). This drew a horrified response and a letter from a group of practitioners and academics (O?Hara, 2010) and has since being abandoned I think. (Details are available on my website.) This was proposed because psychiatric research had found that black people (more often that whites), when diagnosed as schizophrenic as adults, had given a history of family life that did not conform to what researchers assumed to be the ?norm? and so the family life (mainly to do with high single-parentage) was judged to be pathological. ? [In fact I saw the plan for this research way back in 1998 and lobbied the junior minister for mental health to tray and get it revised. He was the danger but after asking his department to investigate came back with the answer that his department could not interfere with medical research approved by the Medical Research Council.] ? In my view, if we are looking for research as a way forward we should look to transcultural theories incorporating anti-racist thinking, a ?critical approach? to psychiatry and western psychology, and evidence of service user experience. What we may then get (if we are trying to explore the high rates of schizophrenia diagnosis for example) is something like a mixture of social forces and diagnostic misperceptions (see Fernando, 2003). But this sort of research cannot get funding ? and may not get past so-called peer review for medical research. [I can illustrate this with anecdotes if you like.] Slide: Diagnosis ? In one of his last papers (co-authored with Jablensky) Bob Kendell, one-time president of the Royal College of Psychiatrists, stated that ?diagnostic categories are simply concepts, justified only by whether they provide a useful framework for organizing and explaining the complexity of clinical experience in order to derive inferences about outcome and to guide decisions about treatment? (Kendell and Jablensky, 2003: 5). The paper warned against reifying a diagnosis by assuming that it is ?an entity of some kind that can be evoked to explain the patient?s symptoms and whose validity need not be questioned? (2003: 5). The same may be said about making assessments for counselling or psychotherapy, by say the intake team of a service. The tendency to accept as correct ? even to reify - the findings of an assessment, that for example the client is too enmeshed in his family or ( a very common diagnosis one time for young black people) has a problem with authority. If you look closely, you may find this is more a reflection of how the assessor draws from his or her (possibly ethnocentric) training about how people should separate from ?family? or the client?s place in society as anything else. ? So in societies where people come from diverse cultural backgrounds, psychiatric diagnoses and ways of assessment (evolved in ?western? culture), if they are to be useful, have to address the fact not just of diversity in how health and illness are understood for example ? but also the judgments about good and bad cultures that we may carry. [extreme example, in Hungary Roma child ?rescued from bad influence.] So perhaps not surprisingly, psychiatric research tied to diagnosis as it is.has produced very little that we can act on ? except perhaps some evidence that racism in society may cause illness through social stress (McKenzie, 2003) or that the explanations may lie in differing pathways into care (e.g. Bhui et al. 2003; Morgan et al. 2005). ? [This lack of progress in ethnic studies has been called (Eaton and Harris, 2000) ?circular epidemiology? (Kuller, 1999) ? a rut in which researchers are in because they refuse to question the dogma of traditional ways of diagnosis and assessment (Fernando, 2003)] ? Recently we saw a dangerous situation arising from social determinants-type research that is popular just now in Britain (and perhaps in Canada too) when done in a medical framework, ? or should I say in a narrow medical framework. The work came from (in fact a very expensive) study from the Institute of Psychiatry (Morgan and Hutchinson, 2010). A national newspaper (the Guardian) in December 2010 quoted that the researchers would back the lead for mental health at government level (the person we call the ?psychiatric tsar?) for a ?program of social engineering? of black family life in order to save black children from becoming ?schizophrenic? (Lewin, 2009). This drew a horrified response and a letter from a group of practitioners and academics (O?Hara, 2010) and has since being abandoned I think. (Details are available on my website.) This was proposed because psychiatric research had found that black people (more often that whites), when diagnosed as schizophrenic as adults, had given a history of family life that did not conform to what researchers assumed to be the ?norm? and so the family life (mainly to do with high single-parentage) was judged to be pathological. ? [In fact I saw the plan for this research way back in 1998 and lobbied the junior minister for mental health to tray and get it revised. He was the danger but after asking his department to investigate came back with the answer that his department could not interfere with medical research approved by the Medical Research Council.] ? In my view, if we are looking for research as a way forward we should look to transcultural theories incorporating anti-racist thinking, a ?critical approach? to psychiatry and western psychology, and evidence of service user experience. What we may then get (if we are trying to explore the high rates of schizophrenia diagnosis for example) is something like a mixture of social forces and diagnostic misperceptions (see Fernando, 2003). But this sort of research cannot get funding ? and may not get past so-called peer review for medical research. [I can illustrate this with anecdotes if you like.]

13. SOCIAL FORCES UNDERPINNING ETHNIC STATISTICS Conflation of medical and social control agendas in ?psychiatry? Medicalization of what is perceived as deviance and difference Political pressures to put away people considered ?dangerous? Social pressures & disadvantage apply differentially on people seen as ?the other? racially and / or politically Sense of alienation of ?the other? seen as their problem

14. DIAGNOSTIC MIS-PERCEPTIONS involving ?race? and ?culture? Because of Cultural dissonance (?culture-clash?) between psychiatry / western psychology and background of clients Assumption of ?objectivity? of diagnosis / psychological assessments and certainty of western cultural thinking Adherence to traditional ethnocentric practice with its racist history Clinical judgements by psychologists and psychiatrists that disregard cultural difference Disregard of service-user perceptions of ?problems? and diversity in expression of distress and anger Influence of stereotypes in clinical judgement Racist perceptions of ?psychosis?, ?schizophrenia?, and dangerousness Slide: Diagnostic misperceptions ? In explaining ethnic issues, some of us talked way back in 1980s about ?institutional racism?. This is a concept first proposed in the 1960s by Stokely Carmichael and Charles Hamilton (1967) in Black Power, to explain educational and social disadvantage in the US, but it is only since the Macpherson report (Home Department, 1999) on failures of the Metropolitan Police in investigating a murder that this concept has come into the mainstream discourse in the UK. Slide: Diagnostic misperceptions ? In explaining ethnic issues, some of us talked way back in 1980s about ?institutional racism?. This is a concept first proposed in the 1960s by Stokely Carmichael and Charles Hamilton (1967) in Black Power, to explain educational and social disadvantage in the US, but it is only since the Macpherson report (Home Department, 1999) on failures of the Metropolitan Police in investigating a murder that this concept has come into the mainstream discourse in the UK.

15. INSTITUTIONAL RACISM ?The collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantages minority ethnic people?. The Stephen Lawrence Inquiry by Sir William Macpherson (Home Department, 1999: 28) Slide: Institutional Racism ? It is increasingly evident I think that the problems in psychiatry - and I suggest this applies to counselling services too ? these are not just about cultural insensitivity (or cultural incompetence) or indeed even about individual racism or (what I could call) old fashioned prejudice (although there is a bit of this still) but about institutional processes embedded in ways of doing things, seeing people, interpreting behaviour, diagnosing, making assessments ? about the assumptions we make about others ? especially people seen as ?the other? (Kapuscinski, 2008) and so on. And the remedy is by no means just a matter of getting black people into positions of apparent authority, as psychiatrists or whatever. As I said, proponents of black power first proposed the term institutional racism. The after-word in the re-issue in 1992 of Black Power (Ture and Hamilton, 1992) talks regretfully of the failure to change systems in spite of opening doors for black people to get into positions of apparent power. ?Powerless visibility? (of the blacks in position of power) is the term coined by them to highlight the issue ? I am not sure that we could claim the same for Obama ? he is certainly visible, almost a superstar - but the institutional racism in the US is as yet untouched. Changing systems is not just about opening doors for black people to go through and this is very evident in the British mental heath scene. ? [Tarique Ali in a TV discussion recently pointed out that the number of African-Americans in prison today is almost exactly the same as the number who were slaves in the mid-19th century. Stokely Carmichael points out that Black power of the 1960s was about supporting a ?black agenda? not just getting black individuals into high places. Comments by Jesse Jackson in 1990s.] ? As I hope I have shown you, the issues underpinning institutional racism are complex and anti-racism strategies to change systems and professional practices have to be complex too. For psychiatric practice - and the same applies to counselling and psychology ? the main issue is of racism incorporated into a variety of institutional processes within the mental health system, its theories, its practices, its ways if thinking and so on ? all this interacting with cultural misunderstandings and outmoded models of health and illness (and may be unsuitable models of psychology too), that somehow fails to grasp the realities of human suffering and misfortune but are tied to ways of practising psychiatry, counselling and psychotherapy. And there is too the context of social pressures and disadvantages, again connected to race, class etc. But the lesson for professional practice may be that in searching for scientific answers using the 19th century paradigm of ?science?, psychiatry, and allied field of care have - to varying extents may be - lost its way as a caring profession and become de-humanised ? and in some contexts, such as modern western societies, institutionally racist. Slide: Institutional Racism ? It is increasingly evident I think that the problems in psychiatry - and I suggest this applies to counselling services too ? these are not just about cultural insensitivity (or cultural incompetence) or indeed even about individual racism or (what I could call) old fashioned prejudice (although there is a bit of this still) but about institutional processes embedded in ways of doing things, seeing people, interpreting behaviour, diagnosing, making assessments ? about the assumptions we make about others ? especially people seen as ?the other? (Kapuscinski, 2008) and so on. And the remedy is by no means just a matter of getting black people into positions of apparent authority, as psychiatrists or whatever. As I said, proponents of black power first proposed the term institutional racism. The after-word in the re-issue in 1992 of Black Power (Ture and Hamilton, 1992) talks regretfully of the failure to change systems in spite of opening doors for black people to get into positions of apparent power. ?Powerless visibility? (of the blacks in position of power) is the term coined by them to highlight the issue ? I am not sure that we could claim the same for Obama ? he is certainly visible, almost a superstar - but the institutional racism in the US is as yet untouched. Changing systems is not just about opening doors for black people to go through and this is very evident in the British mental heath scene. ? [Tarique Ali in a TV discussion recently pointed out that the number of African-Americans in prison today is almost exactly the same as the number who were slaves in the mid-19th century. Stokely Carmichael points out that Black power of the 1960s was about supporting a ?black agenda? not just getting black individuals into high places. Comments by Jesse Jackson in 1990s.] ? As I hope I have shown you, the issues underpinning institutional racism are complex and anti-racism strategies to change systems and professional practices have to be complex too. For psychiatric practice - and the same applies to counselling and psychology ? the main issue is of racism incorporated into a variety of institutional processes within the mental health system, its theories, its practices, its ways if thinking and so on ? all this interacting with cultural misunderstandings and outmoded models of health and illness (and may be unsuitable models of psychology too), that somehow fails to grasp the realities of human suffering and misfortune but are tied to ways of practising psychiatry, counselling and psychotherapy. And there is too the context of social pressures and disadvantages, again connected to race, class etc. But the lesson for professional practice may be that in searching for scientific answers using the 19th century paradigm of ?science?, psychiatry, and allied field of care have - to varying extents may be - lost its way as a caring profession and become de-humanised ? and in some contexts, such as modern western societies, institutionally racist.

16. PERSONAL IDENTITY SELF / EGO EMPHASIS IN ?WESTERN? THINKING SEPARATE AUTONOMOUS IMPORTANT REFLECTED IN PSYCHOLOGY AS: SELF ESTEEM INTEGRITY EGO-BOUNDARIES REFLECTED IN PSYCHIATRY AS: SELF-DEPRECIATION PASSIVITY FEELINGS DEPENDENCY ENMESHED Ref: Fernando, S. (2003) Cultural Diversity, Mental Health & Psychiatry. Brunner-Routledge, Hove & New York. Ethnic identity Individual identity is given a high profile in western psychology - in fact much of western psychology is about the individualised self with a supposedly fixed identity coming about through stages of development during childhood and adolescence. The concept of ?identity crisis? or breakup of identity has been used to explain various diverse problems from alienation and social exclusion to ?psychosis?; from lack of confidence to criminal violence. Traditionally (that?s the western cultural tradition reflected in western psychology), individual identity is seen as being closely tied up with the concept of personal ?self? ? equivalent more or less with the Freudian ?ego?. ? Slide: Personal identity; Self / Ego ? The importance of a personal, reified self is reflected in the way (for example) western psychology values the individual with clear-cut ?ego-boundaries?. All this is implicit in counselling and psychotherapy underpinned by western psychology. In psychiatry, self-depreciation, a form of low self-esteem ? not you may notice other-esteem, respect for other people - self-depreciation is seen as a symptom or sign of clinical depression. So-called passivity feelings (where one?s identity is controlled by external forces) is a sign of schizophrenia; and dependency on other people or one?s identity being enmeshed within (say) that of other members of a family; all these are seen as pathological states if not actual symptoms of illness. ? It is in this setting that, during the past 20 or 30 years, there has been much talk of cultural identity and, to a lesser extent, racial identity ? and both concepts (?culture? and ?race?) get mixed up with others to form what is called ?ethnic identity?. However, this emphasis on individual identity in sort of isolation ? the way western psychology tends to do ? may not represent what is meaningful for many people living in multi-ethnic societies and, in some situations has contributed to serious problems of persecution even genocide. Some people have called this ?identity madness?. I shall come to that in a moment. ? It is a fact however, that self-definition by ethnicity is now well established for registration (census) and monitoring purposes (at least in the UK) and preferred to either ?culture? or ?race? for these purposes. And I must say it has led to some good outcomes in uncovering discrimination or inequality. Looking at the larger scene, (what I called ?identity madness?) Nobel Prize Laureate, Amartya Sen, (2006) critiques the idea that personal identity is fixed or ?destined? (as he puts it), proposing that identity has several traces - several connections as it were - and it is flexible. Ethnic identity Individual identity is given a high profile in western psychology - in fact much of western psychology is about the individualised self with a supposedly fixed identity coming about through stages of development during childhood and adolescence. The concept of ?identity crisis? or breakup of identity has been used to explain various diverse problems from alienation and social exclusion to ?psychosis?; from lack of confidence to criminal violence. Traditionally (that?s the western cultural tradition reflected in western psychology), individual identity is seen as being closely tied up with the concept of personal ?self? ? equivalent more or less with the Freudian ?ego?. ? Slide: Personal identity; Self / Ego ? The importance of a personal, reified self is reflected in the way (for example) western psychology values the individual with clear-cut ?ego-boundaries?. All this is implicit in counselling and psychotherapy underpinned by western psychology. In psychiatry, self-depreciation, a form of low self-esteem ? not you may notice other-esteem, respect for other people - self-depreciation is seen as a symptom or sign of clinical depression. So-called passivity feelings (where one?s identity is controlled by external forces) is a sign of schizophrenia; and dependency on other people or one?s identity being enmeshed within (say) that of other members of a family; all these are seen as pathological states if not actual symptoms of illness. ? It is in this setting that, during the past 20 or 30 years, there has been much talk of cultural identity and, to a lesser extent, racial identity ? and both concepts (?culture? and ?race?) get mixed up with others to form what is called ?ethnic identity?. However, this emphasis on individual identity in sort of isolation ? the way western psychology tends to do ? may not represent what is meaningful for many people living in multi-ethnic societies and, in some situations has contributed to serious problems of persecution even genocide. Some people have called this ?identity madness?. I shall come to that in a moment. ? It is a fact however, that self-definition by ethnicity is now well established for registration (census) and monitoring purposes (at least in the UK) and preferred to either ?culture? or ?race? for these purposes. And I must say it has led to some good outcomes in uncovering discrimination or inequality. Looking at the larger scene, (what I called ?identity madness?) Nobel Prize Laureate, Amartya Sen, (2006) critiques the idea that personal identity is fixed or ?destined? (as he puts it), proposing that identity has several traces - several connections as it were - and it is flexible.

17. PERSONAL IDENTITY COMMUNITY (AND FAMILY) -BASED RELATIONSHIPS (REAL / IMAGINED) PARENTAL (?NOMINAL?) RELIGION ?RACIAL? BACKGROUND OR APPEARANCE HISTORICAL BACKGROUND PROFESSIONAL (OR OTHER ) ALLEGIANCE INDIVIDUAL-BASED (PERSONAL CHOICE) OWN (CHOSEN) RELIGION / BELIEFS LOYALTIES VALUES SENSE OF BELONGING (REAL / IMAGINED) CONTEXTUALLY DETERMINED FORCES IN SOCIETY AT LARGE (E.G. RACISM) CATEGORISATION BY AUTHORITIES PROFESSIONAL OR OTHER ALLEGIANCE Refs. Sen, Amartya (2006) Identity and Violence. The illusion of destiny. London: Allen Lane Anderson, B. (1991) Imagined Communities, Reflections on the Origin and Spread of Nationalism . London and New York: Verso. Fernando, Suman (2010) Mental Health, Race and Culture, third edition Basingstoke: Palgrave Macmillan. Slide: Personal identity ? Amartya Sen argues that personal identity is community and family based, depends on parental (?nominal?) religion, and background, but also perhaps one?s allegiance to a caste or clan that one is born into or a profession that one gets trained into. And in some circumstances we identify by class or where we live or like to live, and so on. But most of all, personal identity comes from a sense of connections, relationships that are real or imagined - as so well described by Benedict Anderson (1991) in Imagined Communities. Another aspect of personal identity is that there is an element of choice or personal inclination ? one?s loyalties, values, sense of belonging to a place or places, perhaps one?s chosen beliefs or religion. Finally, personal identity is contextually determined ? by other people?s perceptions, forces in society such as racism and so on. The reality is that most people hinge their personal identity to a variety of ?things? as it were. Attaching identity to just one thing and imagining that that is absolute all the time and in perpetuity may not occur very often these days ? perhaps never did. In other words, personal identity is flexible and changing ? one ?thing? may be important at one time, and something else, or many others, at another time. ? I suggest that ?ethnic identity? is just one of many identities we carry and indeed several ethnic identities may be held at the same time. This way of seeing identity is characterised by what psychologist Linville (1987) calls ?self-complexity? ? i.e. cognitive awareness of the ?self? being composed of several identities derived from several cultural and social sources, ethnic heritage ? or heritages - being just one or two of these. Roccas and Brewer (2002), also psychologists, call these ?intercultural identities? - I prefer ?flexible identities?. I think this is somewhat different to what is often called bi-culturalism (Berry, 1997) and more like the sort of situation that British sociologist Stuart Hall (1996) means when he talks of ?a bewildering, fleeting multiplicity of possible identities any of which we could identify with ? at least temporarily? (1996: 598). It is not a matter of dividing up one identity into several identities ? all the identities can be held together, the importance of any one being determined by context and choice - by what is needed or desired at any particular time and / or occasion. But this is only a start. ? Many years ago in the early 1960s I carried out a study of depression among Jews in East London (England) (Fernando, 1973). Something I found then ? which I did not focus on very much at the time ? was that links with others they considered ?Jewish? together with adherence to Jewish religious traditions - what I lump together as ?ethnic identity? ? the strength of holding this ethnic identity (as Jewish) seemed to have protected Jews (in my study) from depression, while similar adherence to traditions or connections among non-Jews in that area of London had not had this protective effect (Fernando, 1986). The meaning I make now is that in a context of anti-Semitism ? very active in London when the subjects I studied were growing up ? in such a context, having a strong ethnic identity (as Jewish) was a protective factor (psychologically); something that did not work in the same way for people not subject to ethnic / racial hostility. In other words strong single-ethnic identity protected individuals against the psychological consequences of ethnic hostility / racism. ? Interestingly, Linville (1987), a psychologist in New Haven, has reported experimental findings in a study among students measuring how they saw themselves in an open-ended self-descriptive task in a context of no particular pressures related to ethnicity. Linville found that the impact of negative life events on causing somatic and depressive symptoms were less as the level of self-complexity increased. In other words, holding several identities was a buffer against symptoms of depression in the face of life stresses which were not based on ethnic hostility / racism. So a sort of model emerges. Slide: Personal identity ? Amartya Sen argues that personal identity is community and family based, depends on parental (?nominal?) religion, and background, but also perhaps one?s allegiance to a caste or clan that one is born into or a profession that one gets trained into. And in some circumstances we identify by class or where we live or like to live, and so on. But most of all, personal identity comes from a sense of connections, relationships that are real or imagined - as so well described by Benedict Anderson (1991) in Imagined Communities. Another aspect of personal identity is that there is an element of choice or personal inclination ? one?s loyalties, values, sense of belonging to a place or places, perhaps one?s chosen beliefs or religion. Finally, personal identity is contextually determined ? by other people?s perceptions, forces in society such as racism and so on. The reality is that most people hinge their personal identity to a variety of ?things? as it were. Attaching identity to just one thing and imagining that that is absolute all the time and in perpetuity may not occur very often these days ? perhaps never did. In other words, personal identity is flexible and changing ? one ?thing? may be important at one time, and something else, or many others, at another time. ? I suggest that ?ethnic identity? is just one of many identities we carry and indeed several ethnic identities may be held at the same time. This way of seeing identity is characterised by what psychologist Linville (1987) calls ?self-complexity? ? i.e. cognitive awareness of the ?self? being composed of several identities derived from several cultural and social sources, ethnic heritage ? or heritages - being just one or two of these. Roccas and Brewer (2002), also psychologists, call these ?intercultural identities? - I prefer ?flexible identities?. I think this is somewhat different to what is often called bi-culturalism (Berry, 1997) and more like the sort of situation that British sociologist Stuart Hall (1996) means when he talks of ?a bewildering, fleeting multiplicity of possible identities any of which we could identify with ? at least temporarily? (1996: 598). It is not a matter of dividing up one identity into several identities ? all the identities can be held together, the importance of any one being determined by context and choice - by what is needed or desired at any particular time and / or occasion. But this is only a start. ? Many years ago in the early 1960s I carried out a study of depression among Jews in East London (England) (Fernando, 1973). Something I found then ? which I did not focus on very much at the time ? was that links with others they considered ?Jewish? together with adherence to Jewish religious traditions - what I lump together as ?ethnic identity? ? the strength of holding this ethnic identity (as Jewish) seemed to have protected Jews (in my study) from depression, while similar adherence to traditions or connections among non-Jews in that area of London had not had this protective effect (Fernando, 1986). The meaning I make now is that in a context of anti-Semitism ? very active in London when the subjects I studied were growing up ? in such a context, having a strong ethnic identity (as Jewish) was a protective factor (psychologically); something that did not work in the same way for people not subject to ethnic / racial hostility. In other words strong single-ethnic identity protected individuals against the psychological consequences of ethnic hostility / racism. ? Interestingly, Linville (1987), a psychologist in New Haven, has reported experimental findings in a study among students measuring how they saw themselves in an open-ended self-descriptive task in a context of no particular pressures related to ethnicity. Linville found that the impact of negative life events on causing somatic and depressive symptoms were less as the level of self-complexity increased. In other words, holding several identities was a buffer against symptoms of depression in the face of life stresses which were not based on ethnic hostility / racism. So a sort of model emerges.

18. Ethnic identity in a multicultural context Flexible identity is a buffer against depression in a context of ethnic tolerance Single strong ethnic identity protects from depression in a context of racism References Fernando, S. (1986) ?Depression in ethnic minorities?, in J. L. Cox (ed.) Transcultural Psychiatry. London: Croom Helm pp. 107-138. Linville, P. (1987) ?Self-Complexity as a Cognitive Buffer Against Stress-Related Illness and Depression?, Journal of Personality and Social Psychology, 52(4): 663-676. Slide: Identity in a multicultural context ? Looking at the broader picture in the world today, at the macro level, we see that the sort of over-arching identity where people think of themselves as one thing and nothing else, this sort of ?over-identity? has resulted in conflicts and persecution, has led to political theories about ?clash of civilisations?, and thence to further antagonisms, seeing other people as non-persons, just identities. And at a micro level, in our own society in Britain (and it may be the same in Canada) we are seeing people now who resent being given by (to them) arbitrary personal ethnic identities ? as (say) ?Asian? or ?Black? or ?White? ? something they feel that does not identify them personally as a whole. ? I suggest that using ethnicity (or culture or even ?race?) as a category for monitoring (head-counting) is useful for planning services, for identifying discrimination and injustice, and hopefully correcting them. But such designations are for identifying groups of people for certain purposes; they are not (I think) something that should be fixed on people in a personal way ? not labels or badges that should be pinned on anyone. And ethnic identity should not be made into an over-arching part of how we see ourselves as individuals, it is not our DNA. It is just one of many diverse aspects of the ?self?. ? As you know, questions of identity and race dominates much of Frantz Fanon?s writing. [This is accessible in the English language through translations of his main works as Black Skin, White Masks (Fanon, 1952) and the subsequent The Wretched of the Earth (Fanon, 1961).] Both Frantz Fanon and Homi K. Bhabha (a contemporary sociologist) both taking a psychoanalytic viewpoint, have argued that, although a fixed (ethnic or cultural) personal identities may seem to offer stability and certainty, in fact they merely produce an idealisation with which we can never be identical (Huddart, 2006). In other words, at the ?micro? level of one?s inner world, a strong ethnic identity produces alienation from our sense of self. One of Fanon?s biographers (Patrick Ehlen, 2000) quotes ? or imagines - Fanon as saying: ? I am a BLACK MAN. I AM A WHITE MAN. I am Frenchman, a Martinican, an Algerian. I am a hero to my country and I am traitor to my country. I am the idol of the film, but I am villain of the film. Am I handsome? Yes, of course, but I am ugly. I am darker than my brother and lighter than my father. I am larger than the universe. I sing, I weep, I dance. I am all men, and no man. I am Frantz. I am Frantz Fanon. Who am I? ? (2000: 11, capitals in original). Slide: Identity in a multicultural context ? Looking at the broader picture in the world today, at the macro level, we see that the sort of over-arching identity where people think of themselves as one thing and nothing else, this sort of ?over-identity? has resulted in conflicts and persecution, has led to political theories about ?clash of civilisations?, and thence to further antagonisms, seeing other people as non-persons, just identities. And at a micro level, in our own society in Britain (and it may be the same in Canada) we are seeing people now who resent being given by (to them) arbitrary personal ethnic identities ? as (say) ?Asian? or ?Black? or ?White? ? something they feel that does not identify them personally as a whole. ? I suggest that using ethnicity (or culture or even ?race?) as a category for monitoring (head-counting) is useful for planning services, for identifying discrimination and injustice, and hopefully correcting them. But such designations are for identifying groups of people for certain purposes; they are not (I think) something that should be fixed on people in a personal way ? not labels or badges that should be pinned on anyone. And ethnic identity should not be made into an over-arching part of how we see ourselves as individuals, it is not our DNA. It is just one of many diverse aspects of the ?self?. ? As you know, questions of identity and race dominates much of Frantz Fanon?s writing. [This is accessible in the English language through translations of his main works as Black Skin, White Masks (Fanon, 1952) and the subsequent The Wretched of the Earth (Fanon, 1961).] Both Frantz Fanon and Homi K. Bhabha (a contemporary sociologist) both taking a psychoanalytic viewpoint, have argued that, although a fixed (ethnic or cultural) personal identities may seem to offer stability and certainty, in fact they merely produce an idealisation with which we can never be identical (Huddart, 2006). In other words, at the ?micro? level of one?s inner world, a strong ethnic identity produces alienation from our sense of self. One of Fanon?s biographers (Patrick Ehlen, 2000) quotes ? or imagines - Fanon as saying: ? I am a BLACK MAN. I AM A WHITE MAN. I am Frenchman, a Martinican, an Algerian. I am a hero to my country and I am traitor to my country. I am the idol of the film, but I am villain of the film. Am I handsome? Yes, of course, but I am ugly. I am darker than my brother and lighter than my father. I am larger than the universe. I sing, I weep, I dance. I am all men, and no man. I am Frantz. I am Frantz Fanon. Who am I? ? (2000: 11, capitals in original).

19. WEBSITES www.sumanfernando.com www.bmementalhealth.org.uk http://www.criticalpsychiatry.net www.aen.org.nz www.spn.org.uk Summary Psychiatry and the therapies that have come out of western psychology may have suited social purposes of the nineteenth and first half of the twentieth centuries. But since the dismantling of colonial empires, European society has changed - become ?multi-racial? as well as multicultural ? and the same has happened across the Atlantic, although here carrying the added dimension of indigenous native minorities that predate European settlement, i.e. the first nations. For Europe, the Empire has come home; and our world ? the whole world may be ? has become ?mixed?. ? In the mental health field, racism now mainly takes a subtle but pernicious form; it permeates diagnosis and forms of assessment based on what may well be outdated systems. Government strategies ? or indeed professional practitioners - have singularly failed to do very much about its effects in actual service delivery, except for some clipping of wings and minor adjustments at the periphery. The racism embedded centrally in institutional practices is largely untouched. ? In some parts of the world, a single over-arching personal ethnic identity where people think of themselves as one thing and nothing else, appears to have contributed to conflicts even genocide. Consequently, political theories about ?clash of civilisations? have emerged, promoting further antagonisms, seeing other people ? the ethnic ?other? - as non-persons, just identities. Ethnic categorisation as groups may be useful for monitoring services so that possible points of discrimination can be identified. But fixing personal ethnic identities have limitations. We should all see ourselves as mixed in many ways with identities that are flexible, rejecting the need for an over-arching ethnic identity. But overt ethnic hostility ? racism - is a reality that raises its head sometimes in the most unexpected ways and then a strong, even over-arching, sense of ethnic identity is necessary for psychological survival. Summary Psychiatry and the therapies that have come out of western psychology may have suited social purposes of the nineteenth and first half of the twentieth centuries. But since the dismantling of colonial empires, European society has changed - become ?multi-racial? as well as multicultural ? and the same has happened across the Atlantic, although here carrying the added dimension of indigenous native minorities that predate European settlement, i.e. the first nations. For Europe, the Empire has come home; and our world ? the whole world may be ? has become ?mixed?. ? In the mental health field, racism now mainly takes a subtle but pernicious form; it permeates diagnosis and forms of assessment based on what may well be outdated systems. Government strategies ? or indeed professional practitioners - have singularly failed to do very much about its effects in actual service delivery, except for some clipping of wings and minor adjustments at the periphery. The racism embedded centrally in institutional practices is largely untouched. ? In some parts of the world, a single over-arching personal ethnic identity where people think of themselves as one thing and nothing else, appears to have contributed to conflicts even genocide. Consequently, political theories about ?clash of civilisations? have emerged, promoting further antagonisms, seeing other people ? the ethnic ?other? - as non-persons, just identities. Ethnic categorisation as groups may be useful for monitoring services so that possible points of discrimination can be identified. But fixing personal ethnic identities have limitations. We should all see ourselves as mixed in many ways with identities that are flexible, rejecting the need for an over-arching ethnic identity. But overt ethnic hostility ? racism - is a reality that raises its head sometimes in the most unexpected ways and then a strong, even over-arching, sense of ethnic identity is necessary for psychological survival.


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