The mental health of the South Asian community in Britain

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Introduction
A note on terminology
Researching ‘South Asian’
Historical background
The British South Asian population today
Socio-economic context
    Education
    Employment
    Housing
    Poverty                                                                                                             
Socio-cultural background to the mental health of South Asian people in Britain
    Racism                                                                                                             
    Culture
    Language
    Religion
Mental health needs of South Asian people
    Women
    Men
    Older people
Experiences of mental health services: key concerns
Improving service delivery: what can be done?
Useful organisations
Further reading
References

Introduction

Many of the problems faced by South Asian people who use mental health services are similar to those faced by other minority ethnic communities, though there are differences in access to care and treatment and in the ways people are treated within services and within their own communities. There are also significant similarities and differences in socio-economic and health status.

The provision of mental health services to people of South Asian origin and their experiences of using mental health services have been the subject of research for many decades. Although the need for culturally sensitive care is acknowledged within policy and service provision, the services currently available are far from adequate. This factsheet explores some of these issues and highlights areas of concern.

This factsheet is aimed at mental health professionals and students but will also be of interest to anyone who works with South Asian people.

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A note on terminology

In this factsheet the term ‘South Asian’ refers to people born in India, Pakistan, Bangladesh and Sri Lanka and their descendants, but excludes those born (or descended from those born) in Nepal, Bhutan, the Maldives, Tibet, Afghanistan or the Islamic Republic of Iran.

The terminology of psychiatric diagnosis used reflects the language of the sources referred to. The use of such language in no way implies Mind’s unqualified acceptance of it.

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Researching ‘South Asian’

There are vast national, regional, cultural, religious, linguistic and political differences between the communities that are often studied under the term ‘South Asian’. The term has often been criticised as misleading because it assumes homogeneity, and renders some smaller communities invisible. For example, very little is known about the mental health needs and experiences of Sri Lankan people. Thus, caution needs to be exercised when assumptions are made.

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Historical background

The history and patterns of migration, and the experiences of settling and living in Britain, vary vastly among the communities that constitute the South Asian population of Britain. The following history is an overview of these experiences and trajectories.

There has been a South Asian presence in Britain since the 1600s. Large-scale migration from South Asia began after World War II and continued through the economic boom and labour shortage in the 1950s and 1960s. Some of the immigrants were professionally qualified, but the majority were literate but unskilled labourers from rural areas who found work in manufacturing, engineering and catering industries. The majority of migrants were from Gujarat and Punjab in India, Mirpur in Pakistan and Silhet in Bangladesh. [1] People from Sri Lanka were also part of the migration in the 1950s and 1960s, but a larger number of people migrated to Britain following the civil disturbances in the 1970s. More recently, since the 1980s, working class Tamil people from Sri Lanka have come to Britain as refugees and asylum seekers. [2]

The colonial administration transported South Asians to work as indentured labourers on plantations, roads and railways in other parts of the British Empire, including the West Indies, Mauritius, Guyana, South East Asia and East African countries. This formed the migration route for a large number of people. [3]

Following the ’Africanisation’ policies in Kenya, Uganda and Tanzania, East African Asians began arriving in Britain in the 1960s and 1970s. In 1972, Idi Amin expelled about 80,000 Asians from Uganda, a large number of whom settled in Britain as refugees, amidst great controversy and opposition. [4]

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The British South Asian population today

The 2001 census showed that over half of the minority ethnic population in the UK is of South Asian origin. [5] Indians were the largest minority group, forming 22.7 per cent of the total minority ethnic population; 16.1 per cent were Pakistanis and 6.1 per cent were Bangladeshis. [6] In the 2001 census, Sri Lankans were included in the ‘Asian (Other)’ category, but this is being revised for the next census.

Socio-economic context

At least three generations of South Asians now live in Britain. The vast generational, national and cultural differences in the way South Asians experience life in Britain, their sense of identity and belonging, and socio-cultural aspects of British life are reflected in their socio-economic status. Socio-economic status, along with levels of cultural and institutional exclusion/participation, has been linked to vulnerability to mental health problems. [7], [8]

Education
Children of Pakistani origin were the biggest Asian group in primary schools in the 2001 census, whereas children of Indian origin outnumber Pakistani children in secondary schools. [9]

Employment
The 2001 census showed that rates of unemployment were higher among all South Asian groups than the white population. Indians tended to do better than Pakistanis and Bangladeshis. Unemployment rates were particularly high among the Bangladeshi community, 20 per cent of men and 24 per cent of women being unemployed. [10]

According to 2004 data from the Office of National Statistics (ONS), Bangladeshis and Pakistanis were more likely to be unqualified than white British people. [11]

Housing
According to the 2002 statistics from the ONS, South Asian families tended to be larger than those from other minority ethnic groups, and often had three generations living in one household. [12] The extended family structure was traditionally seen as intrinsic to South Asian communities, giving rise to the stereotype that ’they look after their own’. The cultural practice of living in extended families was transplanted to Britain when people migrated from South Asian countries. However, often families were forced to live together for economic reasons and not necessarily as a means of support.

Poverty
A review of literature published by the Joseph Rowntree Foundation found that poverty rates were high in all South Asian communities. The risk of poverty was highest for Pakistani and Bangladeshi communities, while Indians face above-average poverty compared with white populations. Over half of Pakistani children and almost 70 per cent of Bangladeshi children were growing up in poverty. [13] Poverty rates were also higher for pensioners from these communities.

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Socio-cultural background to the mental health of South Asian people in Britain

As with all immigrant communities, South Asian communities had to face cultural differences, prejudice, racism and alienation in Britain. The communities have evolved and adapted over the course of generations and this is reflected in what we understand as the ‘culture’ of these communities. These experiences have a significant role in the mental health of these people, though this is not often acknowledged in service provision.

Racism
The link between the experience of racism and mental distress is well established. Studies have shown that the ways in which people experience racism as interpersonal violence, institutional racism or socio-economic disadvantage have independent detrimental effects on health. [14], [15] Studies in the last few decades have shown that the social experience of racism is a causative factor in mental health problems, while racism within mental health services results in inappropriate and inadequate service provision.

The complex interaction of racism and mental health and its effect on South Asian communities is further influenced by changing social perceptions of these communities. Recent evidence shows increased animosity towards Muslim groups, and emerging evidence shows that this has an effect on how people from these communities who are also mental health service users are viewed by society. For example, a recent survey of attitudes conducted by Rethink (see ‘Useful organisations’) found that 29 per cent of the people surveyed would not be happy to live next door to a person with mental health problems, but this went up to 47 per cent when asked about living next door to a Muslim person with mental health problems. [16]

According to a research report based on statistics from the British Crime Survey in 2000, South Asian communities were at the greatest risk of being a victim of racially motivated crime – an estimated risk of 3.6 per cent for Indians and 4.2 per cent for Pakistanis and Bangladeshis, compared with 0.3 per cent for white groups and 2.2 per cent for black groups. [17] Subsequent reports in the media, particularly with the increased focus on terrorism, have pointed to an increase in the number of racist incidents targeting people from South Asian communities.

Culture
As suggested earlier, there is a wholly inappropriate tendency within services and in society to see all South Asians as a homogenous group with shared cultural beliefs and practices. Vast differences in national and regional origins, religious beliefs, racial and ethnic subdivisions, language, migratory patterns, experiences of colonialism and extent of Britishness in their identity all influence the wide range of cultural beliefs and practices within the communities.

Culture plays an important part in how communities understand mental health. Evidence shows that many South Asian people understand mental health problems outside of the medical model, and prefer terms such as ’depression‘ and ‘behavioural problems’ to mental illness. [18] It is common to locate the causes of mental health problems in a social context or other external factors (for example, a belief in kismet or fate). In many cultures there is a stigma attached to being mentally ill, and mental health problems are not discussed or disclosed within the community. Several studies involving men and women from South Asian communities have reported on the ideas of family honour (izzat) and personal shame (sharam) as reasons for the stigma and denial of mental health problems that exist within these communities. [19], [20]

While service users and carers have stressed the importance of cultural sensitivity in the provision of mental health services (see ’Experiences of mental health services’) it is important to remember that a focus on cultural definitions can easily slip into stereotyping of South Asian people and their experiences of mental health.

Language
The issue of language in the context of mental health services involves two important factors: the spoken and written language used to communicate, and the language of mental health itself. Evidence shows that the interactions between South Asian communities and mental health services have been affected by both.

South Asian people in Britain speak a wide range of languages. There is no reliable data on the number of people who speak a specific language. A review in 2003 by The Central Office of Information included Bengali, Punjabi, Gujarati, Urdu and Tamil among the top ten languages that it recommended for translating information made available by the Department of Work and Pensions. [21]

Language has been identified as a barrier for service use and appropriate service delivery. [22], [23] Service users and carers interviewed about their experience of services pointed out the need for translators and interpreters, and emphasised the need for people trained in clinical interviewing who can translate the language of psychiatry in a way that people can understand and relate to.

Questions have been raised about the applicability of certain assessment tools to people from minority ethnic backgrounds, particularly when there is little understanding of their cultures and how they interpret life. [24] Difficulties in interpreting and understanding psychiatric terms and a person’s emotions can lead to misdiagnosis and therefore inappropriate treatment. In this sense, the language barrier goes beyond that of the specific language, and points to a difference between eurocentric psychiatric models of mental ill-health and culturally specific understandings of experiences and emotions.

Religion
The largest faith groups of South Asian people in Britain are Pakistani Muslims, Indian Hindus, Indian Sikhs and Bangladeshi Muslims. [25] Religion, faith and spirituality play important roles in the way people understand and interpret their mental and emotional lives. There are both commonalities and differences in religious practices between the various religious traditions and cultural variations. A person who has a strong religious identity may understand mental health issues in a different way to someone with a eurocentric medical understanding. This can become an issue when people come into contact with mental health services, as their needs may not be matched by the services available.

For many people, faith and spirituality play important parts in healing and recovery. In a recent study of the Pakistani community’s views of mental health services in Birmingham, 59 per cent of participants said that religious worship played an important part in the way they coped with mental health problems. [26] Prayer and religion were also found to be a main coping strategy for Asian women who were interviewed in a small-scale study of people experiencing depression. [27] The need to take people’s religious and spiritual needs into consideration when planning treatment and care is now more widely acknowledged – the Royal College of Psychiatrists has a special interest group in spirituality and mental health.

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Mental health needs of South Asian people

Several studies in the last few decades have explored the prevalence of mental health problems in South Asian communities, the majority of which have focused on South Asian women; fewer studies have explored issues experienced by South Asian men. The findings of these studies have often been contradictory and inconclusive, [28], [29] and several factors have been identified as reasons for a disparity. Some (for example, studies on depression among Asian women) tended to study South Asian communities as one homogenous group, but found different results when subgroups are studied separately. Some used research and assessment tools that did not capture cultural diversity in the understanding and meaning of mental distress, while others did not allow for generational or cultural differences between groups.

Women
Traditionally, depression, suicide and self-harm are seen as significant problems for South Asian women, particularly young women. [30] Several factors affect the mental health of these women. A study by the Newham Asian Women’s Project of girls and young women between 11 and 25 years of age from all backgrounds found that most of the factors affecting their emotional health were similar, regardless of class or ethnic background. However, young women from South Asian backgrounds faced a number of barriers to accessing support. These included the male privilege existing in some communities and families, the difficulty that some associated with being part of a tight-knit community, and the idea of family honour (izzat). [31]

Studies exploring the experiences of women diagnosed with depression and other mental health problems highlight similar issues. The need to conform to social and cultural values, experience of violence and abuse, and social isolation are key factors affecting their mental health. However, assumptions about ‘South Asian cultures‘ and stereotypes about women from these cultures have meant that service provision does not address these issues. [32], [33] Social isolation, language problems and the anticipation of racism and cultural exclusion also affect women’s access to mental health care.

Men
South Asian men have not been the focus of many studies. A common myth is that they do not need any mental health services and will be looked after by their families. One study suggested that there could be many reasons why South Asian men’s health is studied less than that of women. These reasons include stigma, an unwillingness to participate in such studies, influenced by ideas about men’s roles, and the expectation that Asian men perceive coping with distress as part of their expected response to adversity. [34]

The above-mentioned study, conducted in London, found problems in the way assessments were made and diagnoses explained. A lack of adequate attention to religious and cultural needs was also highlighted, along with choice of key workers and the extent of involvement of family members. The study also highlighted the need for cultural competency training that includes differing expectations of help and health beliefs.

Recent research has addressed the issues of alcohol consumption and drug use among Asian men. A study of ethnic differences in alcoholic cirrhosis in West Birmingham found that Asian men were over-represented compared with other ethnic groups. Almost all of these men were from non-Muslim backgrounds and younger than the patients from white backgrounds. [35] While the reasons for increased alcohol consumption among South Asian men are not clear, it has been seen as a means of self-medication that allows them to maintain their cultural gender roles, and also a result of socio-economic deprivation. [36]

A recent study that retrospectively reviewed case notes and (Mental Health Act) sections papers over one year in a psychiatric unit found that, compared with Caucasians, Asian people were significantly over-represented as inpatients and were more likely to be detained both at admission and under longer term powers. [37] There is also emerging evidence that the recent media attention and focus on Muslims in Britain has had adverse effects on the mental health of South Asian men. [38] The reflection of this in service provision has yet to be studied.

Older people
South Asian populations, like other minority ethnic groups, have a younger age structure than the white population in Britain, though the number of older people is predicted to rise in forthcoming years. [39] There is also evidence that the impact of aging in terms of health and social care needs is felt at a comparatively younger age in many minority ethnic communities. [40] Among South Asian communities, those of Indian origin have the highest number of older people. A substantial number of older people are those who migrated in the 1950s and 60s, and may have come with short-term plans but with the intention of returning to their country of birth. Racism, social isolation and exclusion, along with poverty, have been realities for many of them. [41]

A recent finding showed an alarming increase in the number of suicides among older Asian women compared with white women, [42] linked to long-term illness and bereavement. Older people are also likely to have less information about the type of services available, and hence less access to services, because of language barriers and social isolation. The common assumption that older people in South Asian communities are looked after by their families and communities has been challenged in recent research. A study of 105 carers from Punjabi Sikh, Gujarati Hindu and Bangladeshi and Pakistani Muslim communities found that carers had limited support within nuclear and extended families. The study also showed that fear of stigma and a sense of obligation prevented the carers from accessing help from wider networks – findings that have clear implications for policy makers and service providers. [43]

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Experiences of mental health services: key concerns

User-led research that explores the experiences of service users and carers from South Asian communities is scarce, but some record of what these experiences have been comes from other research studies. The following key concerns have been raised by service users and carers.

• Information about, and access to, services that are appropriate for these communities’ needs is inadequate. Reasons for this include stereotypes about South Asian communities (including the assumption that ‘they look after their own’), language barriers and social isolation.
• Once in contact with services, the service user’s experience of assessment and treatment is often negative. Reasons for this include a lack of understanding of their culture, racism, gaps in the availability of appropriate services, lack of support in understanding psychiatric diagnoses, and inadequate support for carers.
• There is often no place for religious and cultural beliefs in assessment and care planning. Mental health professionals disregarded these needs more often than not.
• Service users and carers argue for more culturally sensitive services and feel that mental health professionals should be trained in the provision of services that meet the needs of those accessing them. However, some service users feel that a focus on cultural appropriateness sometimes means that specific issues around the oppression of more vulnerable groups in communities goes unnoticed. For example, the oppression of South Asian women is often overlooked or excused on the grounds that the culture allows men to have the upper hand.
• Stereotypes of South Asian cultures and men and women results in assumptions about their mental health, which are reflected in care delivery.
• There is a need for appropriately trained interpreters and translators to help professionals and service users communicate more effectively and reduce the chances of misdiagnosis and inappropriate treatment.

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Improving service delivery: what can be done?

Several organisations are working to improve the mental health of South Asian people (see ‘Useful organisations’). Improvements in service provision should be negotiated in consultation with such organisations. Service users and carers should be at the centre of service improvement and innovation. There is also a need to explore mental health needs within specific communities.

The Delivering Race Equality [44] programme, set up in 2005, aims to tackle mental health inequalities faced by people from black and minority ethnic communities, and to create a situation where people from these communities feel more able to access services and have greater confidence in them. A variety of community engagement projects are working towards these goals. [45] Evidence from these projects should provide the basis for improvement of local services, with the involvement of communities, service users and carers. There is now a significant focus on user involvement in mental health services, but the experiences of service users from minority ethnic backgrounds participating in these initiatives has not always been positive. [46], [47] Service users can play a significant part in commissioning services that are appropriate for them, but for this to become a meaningful reality major shifts in the way organisations and services operate are required. [48]

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Useful organisations

Age Concern BME Elders Forum
National Development and Policy Officer (BME Elders)
Age Concern England
tel: 020 8765 7718
web: www.ageconcern.org.uk/AgeConcern/bme_forum.asp 
An initiative of Age Concern England, the forum aims to represent the interests of a wide range of black and minority ethnic elders and organisations working with them, to influence policy, to exchange good practice and support each other. Also publishes a newsletter.

Asian Family Counselling Service
Suite 51, Windmill Place, 2–4 Windmill Lane, Southall UB2 4NL
tel: 020 8571 3933 or 020 8813 9714
email: info@asianfamilycounselling.org.uk 
web: www.asianfamilycounselling.org.uk 
Offers counselling services for individuals, couples and families from South Asian communities, in English, Urdu, Punjabi, Hindi and Gujarati. Runs a range of groups around post-natal depression, self-harm, abuse, relationships (all sexual orientations).

Asian Resource Centre
110 Hamstead Road, Handsworth, Birmingham B20 2QS
tel: 0121 523 0580
email: barc@asianresource.org.uk 
web: www.asianresource.org.uk 
Provides a range of services, including advice, legal aid, home visits and elders project. Languages used include Punjabi, Hindi, Urdu, Bengali, Sylheti, Gujarati and Mirpuri.

Catch-a-Fiya Network
27–29 Vauxhall Grove, Vauxhall, London SW8 1SY
tel: 020 7582 0812/0512
email: info@catchafiya.org 
web: www.catchafiya.org 
A project of the Afiya Trust, Catch-a-Fiya is a national network for service users and carers from black and minority ethnic communities. The forum is service user led and aims to support service users to build their capacity, share learning, and influence policy and service delivery. Catch-a-Fiya helps service users to set up regional user forums.

Confederation of Indian Organisations (CIO)
5 Westminster Bridge Rd, London SE1 7XW
tel: 020 7928 9889
email: headoffice@cio.org.uk 
web: www.cio.org.uk 
CIO is a UK-wide umbrella organisation working with South Asian organisations. CIO aims to provide and develop high-quality services that strengthen these organisations and be a strong voice on policy issues that affect the South Asian community. CIO also provides culturally appropriate counselling services around a range of issues, including cultural isolation, domestic violence, sexuality, marriage, depression etc. Has offices in London, Leicester and Manchester.

Joseph Rowntree Foundation
Head Office, The Homestead, 40 Water End, York YO30 6WP
tel: 01904 629 241
email: info@jrf.org.uk
web: www.jrf.org.uk
The Joseph Rowntree Foundation aims to examine the roots of poverty and disadvantage, and to identify solutions, to find ways to empower communities to have control of their own lives, and to contribute to the building and development of strong cohesive and sustainable communities.

Mothertongue
PO Box 2409, Reading RG1 1ZQ
tel: 0118 957 6393
email: info@mothertongue.org.uk
web: www.mothertongue.org.uk 
Mothertongue is a multi-ethnic, culturally sensitive, professional counselling and listening service where people are heard with respect in their chosen language. The charity offers holistic support to people and professional development to staff and volunteers from black and minority ethnic communities.

Muslim Youth Helpline
2nd Floor, 18 Rosemont Road, London NW3 6NE
tel: 0870 774 3518; helpline: 0808 808 2008
email: info@myh.org.uk 
web: www.myh.org.uk and www.muslimyouth.net 
Offers faith and culturally sensitive services to young Muslim people. Counselling services are available nationally via telephone, email and internet, and face to face in the Greater London area. Also runs www.muslimyouth.net, a peer support site run by young people from a diverse range of Muslim backgrounds.

Nafsiyat Intercultural Therapy Centre
262 Holloway Road, London N7 6NE
tel: 020 7686 8666
email: admin@nafsiyat.org.uk 
web: www.nafsiyat.org.uk 
Provides intercultural psychodynamic psychotherapy to people from a wide range of cultural backgrounds. Intercultural therapy takes into consideration the internal realities of culture (beliefs, values, religion and language) and external realities (poverty, refugee status, racism, sexism etc.) of a person. Access is through written referrals and appointment.

Newham Asian Women’s Project
661 Barking Road, Plaistow, London E13 9EX
tel: 020 8472 0528
email: info@nawp.org 
web: www.nawp.org
Provides services specifically aimed at women and children from South Asian backgrounds. Includes safe and emergency housing, counselling and support around self-harm and experiences of violence and abuse, training to increase confidence and chances of employment, and rights-based advice services. The Zindagi project is aimed at young Asian women from East London who are vulnerable to self-harm and suicide.

Pakistani Resource Centre
1 Great Marlbrough Street, Manchester M1 5NJ
tel: 0161 237 1125
email: info@pakistani-resource.org.uk
web: www.pakistani-resource.org.uk 
The Pakistani Resource Centre aims to empower the South Asian Communities within Greater Manchester. It offers counselling and emotional and practical support to individuals experiencing mental ill health, and their carers and family. It also runs the Trafford Mental Health Service, which offers culturally appropriate mental healthcare to people from the region. Services are offered in a range of languages, including Urdu, Punjabi and Mirpuri.

Refugee Council
Head Office, 240–250 Ferndale Road, Brixton, London SW9 8BB
tel: 020 7346 6700; London advice line 020 7346 6777
website: www.refugeecouncil.org.uk 
Gives help and support to asylum seekers and refugees and works to ensure that their needs and concerns are addressed.

Rethink
89 Albert Embankment, London SE1 7TP
tel: 0845 456 0455 (information); advice line 020 7840 3188
email: info@rethink.org or advice@rethink.org
website: www.rethink.org 
Rethink is a charity working with people affected by severe mental illness, providing services, support and information.

Sainsbury Centre for Mental Health
134–138 Borough High Street, London SE1 1LB
tel: 020 7827 8300
email: contact@scmh.org.uk
website: www.scmh.org.uk 
The Sainsbury Centre for Mental Health aims to improve the quality of life for people with mental health problems by influencing policy and practice in mental health and related services, focusing on criminal justice and employment and supporting work on broader mental health and public policy.

Sharing Voices Bradford
99 Maninghams Lane, Bradford BD1 3BN
tel: 01274 7311 66
email: info@sharingvoices.org.uk
web: www.sharingvoices.org.uk 
A mental health community development organisation working primarily in the inner-city areas of Bradford. Service delivery focuses around self-help and mutual support, and includes groups around creative expressions, music, fitness, mutual interest and befriending. There is also a faith-based community self-help group for South Asian women and for Muslim men of all nationalities.

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Further reading

Publications available from Mind

Factsheets (available on Mind’s website at www.mind.org.uk/information)

• Men’s mental health 
• Mental health in translation 
• Mental health of the African Caribbean community in Britain 
• Mental health of Chinese and Vietnamese people in Britain 
• Mental health of Irish people in Britain 
• Older people and mental health 
• Public attitudes to mental distress 
• Statistics 3: Race, culture and mental health 
• Suicide rates, risks and prevention strategies 
• Women and mental health 

Some of Mind’s mental health information booklets have been translated into community languages and can be found at www.mind.org.uk/Information/BT.htm

Publications available from other sources

• Boyle CM, Lee MJ. 2008. Fast Facts: Religion and medicine. Health Press, Oxford
• Silent Scream – Asian women, Self-Harm and Suicide: A Practical Handbook for Professionals working with Asian women. Newham Asian Women’s Project, London.
• Department of Health. 2004. Celebrating our cultures: guidelines for mental health promotion with the South Asian Community. DH, London.
• Visram R. 2002, Asians in Britain: 400 Years of History. Pluto Press: London.

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References