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Black History Month 2011: some reflections on ethnicity and psychiatry
Posted Thursday 6 October 2011
In the first of four blogs marking Black History Month, Sashi Sashidharan looks at the historical role of race in Western psychiatric theory and practice.
The relationship between race and mental health has been problematic within psychiatry over many years. Government policies in this area have become so weakened that there is little prospect of any meaningful change. Writing at the start of Black History Month 2011, it is useful go back to the foundations of this failure.
There are many reasons for the current stalemate in addressing ethnicity or race within psychiatry. What I want to deal with here is the past academic foolishness; the legacy of ‘race science’ and what came to be known as ‘transcultural psychiatry’. In my view, its legacy continues to damage our efforts to reform current psychiatric practice.
Benjamin Rush (1746–1813) signed the Declaration of Independence and campaigned for mental health reform and abolition of slavery. He is known as the Father of American Psychiatry. (His portrait still adorns the official seal of the American Psychiatric Association). But even enlightened (for the time) physicians such as Rush saw African slaves as suffering from an affliction called ‘negritude’, (defined in terms of the colour of their skin). This was described at the time as akin to a mild form of leprosy. (See Vanessa Jackson’s "In Our Own Voices: African American Stories of Oppression, Survival and Recovery in the Mental Health System”.)
Rush reported that “the Africans become insane, we are told, in some instances, soon after they enter upon the toils of perpetual slavery in the West Indies". However, the trauma of slavery was rarely talked about within psychiatry in the 19th and 20th centuries. The preoccupation of ‘mind doctors’ in the United States became more and more fixed on race differences, explicitly used to affirm white superiority in biological and cultural terms.
In Europe, at the same time, the project of scientific racism was gathering strength. This was an attempt to provide a scientific basis for notions of racial superiority. A more significant development, however, in the first half of the 19th century was the emergence of what came to be known as comparative psychiatry, later repackaged as transcultural psychiatry. Essentially, this was an attempt to compare mental distress in different races or cultures. The main point of comparison was across European and non-European people, with Europeans always assumed to be the norm.
Comparative psychiatry was concerned with the symptoms and appearance of mental illness (and their presumed origins) in different cultures. Emil Kraepelin, a highly influential German psychiatrist, who many see as the original architect of the current diagnostic classification system in psychiatry, was a key figure in this field. One of the first tasks that Kraepelin set for himself, after he published his highly influential book on classification (he was the first person to identify schizophrenia as a discrete mental illness), was to establish the position that schizophrenia affected people all across the world.
In 1904 Kraepelin set sail to the Dutch East Indies (modern-day Indonesia) along with his brother Karl, an eminent naturalist. He studied patients in a mental asylum on the island of Java and was soon satisfied that schizophrenia affected the natives as well as the colonial settlers. Kraepelin’s conclusion that psychiatric diagnoses and his classificatory system, originally derived from observations of long-term psychiatric patients in European mental hospitals, could be applied to anyone, anywhere. This had a profound effect on the subsequent development of modern psychiatry.
We continue to use the Kraepelinian classificatory system in practice today. Whether these illness categories (diagnoses such as depression and schizophrenia) mean the same thing in different groups of people – different in terms of culture, religion and language – is sadly not a question that we often hear within contemporary psychiatry.
The continuing crisis around black people’s mental health in England means it’s essential that we engage with these discomforting areas in psychiatry, and I do believe we need to look at these ‘discomforting’ areas in modern psychiatry. Moving beyond current diagnostic categories is part of this process.
Sashi Sashidharan
Sashi is a consultant psychiatrist who campaigns for race equality in mental health services. He is the Director of Mental Health Rights, a voluntary organisation based in Glasgow. Marcel Vige, Mind's Diverse Minds manager, will be replying to comments in Sashi's place.
8 Comments
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Pretty insightful. Thanks!
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What about the many white people of western origin who are not able to consult with a psychiatrist of their own background? Potential for many misunderstandings there, especially in relation to the family and the role of women. Particularly important when talking about abuse within the family - we shouldn't be afraid to discuss this. There are some psychiatric units where nearly every doctor is of Asian origin.
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@ dymphna, Issue isn't so much the race/ethnicity of a particular professional or patient. Both coming from the same ethnic group doesn't mean the interaction will be better than if they come form different groups. Issue that Sashi is addressing is the conceptual framework in which psychiatrists, of whatever ethnicity, operate. Like any health profession's conceptual framework, psychiatry has established ways of understanding and responding to what it defines as illness and wellness. As Sashi points out, these weren't developed in a vacuum. They're based on value-judgements of what is normal/deviant behaviour, which are in fact about which peoples/cultures are seen as "normal", "other", "primitive", "deviant" by the cultural group from which psychiatry as a profession emerged. The consequence of this in terms of over-representation of particular groups within secure mental health settings, and the challenge this poses to modern psychiatry is the point of Sashi's posting.
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' Both coming from the same ethnic group doesn't mean the interaction will be better than if they come form different groups.'
I disagree as I think it helps to come from the same ethnic group when the issue is one of child sexual abuse and incest. Doesn't guarantee understanding but makes it easier. It is very difficult being a young woman in conflict with one's family and having a male psychiatrist from a culture where sexual abuse isn't even a crime and obedience to one's family is the cultural norm.
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By the way is this the same Dr Sashidharan who appeared on Channel Four's After Dark TV programme many years ago on a mental health debate? If so, I was not impressed with the views he expressed on mental health.
{I am aware of the over representation of ethnic minorities in psychiatric units especially secure facilities.}
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@ dymphna, not sure about the After Dark program, but possible.
RE my point about client/professional coming from same ethnic group or not, as you indicate, it may increase potential for shared understanding if both share similar experiences/cultural frames-of-reference. It’s just that it doesn't necessarily guarantee understanding (as you acknowledge) - I should have included the term ‘necessarily’ in my original post.
My main point is that notwithstanding the issue you've raised about patients accessing professionals of the same ethnic origin (and/or gender), that wasn't the focus of Sahi's posting. Issue raised by Sashi was about the cultural origins of psychiatry, and its implications for the way different groups/communities experience the profession. Would be interesting to hear thoughts on this issue from yourself and others reading this blog.
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i love people
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Sashi's posting contains two statements that I agree with.
The first is near the start of the posting. "Government policies in this area have become so weakened that there is little prospect of any meaningful change."
The second is the final sentence of the posting. "Moving beyond current diagnostic policies is part of this process."
Sashi does not elaborate in any way on how or in what direction this moving beyond current diagnostic policies should proceed.
Commenting is now closed.