issue 209 - July 1990
The same difference
The greatest Western psychoanalysts were tainted by racism. Suman Fernando points
the way to a view of mental health that would be worthy of our rich and diverse world.
Sigmund Freud once drew parallels between 'the mental lives of savages and (European) neurotics'. Carl Jung, writing about black Americans in the 1930s, believed that 'the inferior man exercises a tremendous pull upon civilized beings who are forced to live with him, because he fascinates the inferior layers of our psyche'.
Racism is not dead. It is deeply embedded in Western culture - so deeply that few are aware, for example, how far both Freud and Jung integrated it into Western psychological theories. They were, of course, only reflecting commonly-held views of the time.
Today reactionary forces, such as the overtly racist National Front in France, seem to be gaining ground. Adherence to ethnic identities appears to be growing in strength all over the world.
On the other hand, races and ethnic groups are increasingly having to interact and learn to live together. People the world over are really not that different! In the field of mental health, the concepts of 'illness' and 'madness' reach across cultures. There is common, very fertile ground here.
But for this to be productive, and a new, better, more genuinely 'global' understanding of mental health to emerge, Western culture and psychiatry simply have to come to terms with their own racism. Racism is not unique to Western culture - what matters is that at present the West has the economic and political power to go with it.
Throughout the past 300 years racism has distorted Western thinking about other people and their cultures. First, Rousseau's concept of the 'Noble Savage' proposed that 'savages' who lacked the civilizing influence of Western culture were free of mental disorder and it was this idea that many psychiatrists in England, France and the US latched on to in the late eighteenth and the nineteenth centuries. Second, about the same time, there was a view in Europe that non-Europeans were mentally degenerate because they lacked Western culture. Finally, some psychiatrists in the US argued that the black person was relatively free of madness in a state of slavery, but became prey to mental disturbance when set free.
Underlying all these views were racist assumptions about black people, their cultures and their place in society; civilization was associated with white races and primitiveness with others.
A new approach to mental health must stand apart from existing power structures. It must accept the fact that most of the world is neither culturally Western nor racially white. It must recognize the validity of the black experience in a white-dominated world. It should acknowledge the importance of concepts about human life from Asia and Africa and the relativity of all 'knowledge' in a subject that encompasses human feelings, beliefs and behaviour.
First of all, we have to redefine mental illness. Many forms of human distress and misbehaviour, seen through Western eyes as 'illness', are not medicalized in other cultures. Eastern psychotherapies, for example, deal with contemplative awareness; 'neurosis' can be a path to enlightenment for a Buddhist.
Much of Western psychotherapy is currently directed towards problem-solving or decision-making, reflecting the value given to personal self-sufficiency and the control of events by Western culture. In Western thinking an illness is generated by causes arising from biological or psychological change.
In older cultures all changes are seen as relative - as in the thinking of modern physics. And it is just possible that Western ideas in psychiatry could be incorporated into a relativity model. Biochemical and genetic influences might come to be better understood in dynamic balance or imbalance with each other, and with others - social, cultural, spiritual and cosmological.
In psychiatric research and theory, self-knowledge could eventually replace objectivity as the basis for understanding. Psychiatry would take on the study of consciousness, including altered states of consciousness, without identifying some states as 'pathological'. So people who 'hear voices' or have intensely meaningful experiences would no longer be seen as 'pathologically hallucinated' or 'suffering' from various symptoms. Illness would be about disturbances of balance - within individuals, families, and societies in relation to the universe.
The second thing we have to do is restructure the way we organize mental health care. The World Health Organization (WHO) spreads the gospel according to Western psychiatry. The ethos of psychiatry suits the marketing of Western drugs and fails to address racism. So, rightly or wrongly, one gets the impression that the WHO itself is condoning racism and is dominated by Western economic interests. This alliance must be broken.
At a national level changes are needed in both rich and poor countries. Western economic pressure may be creating mental ill-health in the Third World; and Western 'hi-tech' psychiatric methods are so inappropriate in this context that they may be doing little to mend the damage. Western 'aid' in the mental-health field must change gear to address the needs of the people it us supposed to help: concentrate on the villages and towns where most poor people live; require as little capital investment and new training as possible; and make the maximum use of local talent and resources.
In the Third World, governments and mental-health professionals must also change their attitudes. They must face up to the limitations of the Western model - though the baby of Western expertise should not be thrown out with the bathwater of its failings.
Finally, mental health must be seen as something applicable to people - to individuals, families and communities. So promoting mental health is about personal interactions, the stability of communities, relationships between groups of people and even matters of international peace and harmony.
The principles of mental-health promotion must be clear: a commitment to social equity, community participation and ensuring a technical fit' with what can actually be achieved on the ground. Mental-health promotion programmes in the Third World must start off with clear aims before seeking help from Western countries. They must steer clear of any involvement with Western drug firms.
The final vision is of a world in which the concept of illness would remain but would not be fixed in firm categories assumed to be universal. Mental health is not unlike happiness or sorrow, which are relative rather than absolute. There would be diversity within unity.
Different cultures should be understood as different paths towards the same basic goal - that of living together in peace, in communion with one another and our environment. Mental health is different because of culture and race yet the same irrespective of either. That is a paradox - but it is also the reality.
Suman Fernando is a psychiatrist at Chase Farm Hospital in Enfield, UK. He is Chair of the Transcultural Psychiatry Society (UK). His book Mental Health, Race and Culture will be published by Macmillan in 1991.
No word for anxiety
Our training as mental-health professionals is supposed to be 'colour blind'. That sounds fine but in practice it means that people from black and ethnic groups get a raw deal because their particular problems are seldom acknowledged. Even when they are provided for it usually amounts to their being dumped on the few professionals from black and ethnic groups.
So we decided to pilot a project involving Bangladeshi women from Tower Hamlets in the East End of London. The largest Bangladeshi community in Britain lives in Tower Hamlets - at least 40,000 people. Most migrated in the 1960s and 1970s. Adjustment was difficult and the transition from a rural to an inner-city setting was hardest for women. They found themselves confined indoors, isolated and without the networks of social support they were used to in Bangladesh.
Many of these women turned to their doctors with common symptoms of anxiety, such as palpitations, headaches, tearfulness, sleeping difficulties, chest pains, loss of appetite and lack of energy. They were usually prescribed tranquillizers or even placebos like ascorbic acid (Vitamin C). Since the underlying causes remained, the women visited their doctors with increasing frequency. And some were referred on to mental-health professionals like us.
We wanted to see how normal Western approaches to anxiety problems might work when applied across cultures. Our first step was to get an anxiety-management package translated. No easy task: there is no colloquial expression in Bangla for 'anxiety'. We used two approximations, dushchinta ('undue worries') and udhbeg (a word generally used only in its written form).
We knew we had to have a women-only group. A mixed one would have been unacceptable to both the women and their families. Bangladeshi women rarely go out alone. Their cultural background is that of a small rural community where women tend to go out with family members or neighbours. In Britain they are even less likely to go out due to fear of racist abuse and harassment, as well as language difficulties.
So many things in the standard approach had to be changed. We had to translate many of the usual examples - we would normally compare learning to relax with learning to drive, for instance, which would not have been culturally appropriate. At first we asked the women to rate, on a scale one to ten, the effect of relaxation on their level of anxiety. They found numbers an odd way of expressing how they were feeling. So we shifted our focus to words and talked of five stages from 'very good' to 'very bad'.
It was a pilot project, so there were shortcomings. We looked for too little backup, naively taking on too much, like driving the women to and from the centre. We did not collect as much objective data as we might have done with a white group. We fell into the white stereotype of assuming that Bangladeshi women would find the use of various checklists and written records foreign. Perhaps racism has conditioned us to a greater extent than we expected.
But the rapport between us and the women in the group was instantaneous, probably because we share not just a language and culture but a common experience of racism. The importance of having bilingual and ethnic staff is clear.
We found that using a Western model across cultures has potential. But it needs political, financial and personal commitment. And the lack of response by the authorities in Tower Hamlets leads us to conclude that 'institutional' racism is very much alive and kicking.
Aruna Mahtani and Afreen Huq are clinical psychologists. Aruna Mahtani is co-author of Transcultural Counselling in Action (Sage).