In many respects it is difficult to fault the report Understanding Psychosis and Schizophrenia, recently published by the British Psychological Society (BPS) and the Division of Clinical Psychology (DCP); indeed, there is much to admire in it. Whilst not overtly attacking biomedical interpretations of psychosis, it rightly draws attention to the limitations and problems of this model, and points instead to the importance of contexts of adversity, oppression and abuse in understanding psychosis. It also highlights the value of psychological interventions, and in particular, it proposes that people should be offered the opportunity to talk about their experiences in order to make sense of them. Mental health professionals should not impose a particular model or system of understanding on people who experience psychosis, such as their experiences are ‘symptoms’ of mental illness requiring medication.
It is impossible not to agree with this, and it would appear to be churlish or mealy-mouthed to pick holes in such a finely woven fabric. But before getting carried away with eulogy it is worth noting that the colour of this fabric is white, for the most part dazzlingly so. In the rainbow, multi-hued society that is Britain today. This is a glaring omission.
The report makes only scant, fleeting references to the role of cultural differences and the complex relationships that are apparent between such differences and individual experiences of psychosis, whether these relationships are for good or ill. For example, it points out that in Britain, people from African-Caribbean communities are much more likely to receive a diagnosis of schizophrenia than people from white communities, presumably because of ‘…social deprivation and disadvantage…’ (page 45). The racism that provides the daily backdrop to the lived experience of people from non-white (and some white, for example Irish and Eastern European) communities is referred to briefly on page 47, as one of several factors alongside bullying and abuse that makes paranoia understandable. But after this, racism sinks without trace in the rest of the report. There is a brief paragraph on culture on page 14, which draws attention to its importance in providing a context within which people from different traditions talk about their experiences, for example, in spiritual terms, but again, this matter too sinks without trace. Why are these omissions so serious in a report of this nature?
The last sixty years have witnessed the accumulation of a vast body of evidence indicating that people from non-Western traditions have very different experiences of and outcomes from their involvement with mental health services. This is an area too large to be given justice in the confines of a blog, but there are several excellent reviews and overviews of the problem . Early studies carried out in the 1960s in London, Birmingham, Nottingham and Manchester, all cities with growing black communities, found that black people had rates of schizophrenia between 2.5 to 14.6 times higher than the white community (see 4 for an excellent overview of these early studies). A more recent study carried out in London, Nottingham and Bristol found higher rates for schizophrenic and manic psychoses in African-Caribbean people, and black African men and women compared with white groups. The rates of schizophrenia were 9.1 times higher in African-Caribbean people, and 5.8 times higher in black African people.
Not surprisingly these apparently higher rates of ‘schizophrenia’ are associated with a greater likelihood that Black people will receive physical, as opposed to psychological or ‘talking’ therapies. They are also much more likely to receive physical treatments coercively, as involuntary patients in secure and forensic units (see, for example, ). One interpretation of these figures in the light of the submerged racist beliefs that white people have held historically about black people, is that their feelings and emotions are less refined and cruder than those of white people, because they are less intelligent. Consequently they are much more likely to require coercive physical treatments. The corollary holds of course; that being less intelligent they are less likely to benefit from psychological or talking therapies.
In any case, there is good evidence that black people’s personal experiences of day-to-day racism is linked to psychosis. Karlsen et al examined the impact of racism on the mental health of different ethnic groups in England. They used data from a follow-up survey of a sample of people drawn from minority ethnic communities who had participated in the 1999 Health for England study, together with a white English sample. The minority community sample included 793 Irish, 691 Caribbean, 650 Bangladeshi, 648 Indian, and 724 Pakistani people. In addition to questions about experiences of racism, they also asked subjects if they had ever been refused a job or treated unfairly at work on grounds of race, colour, ethnicity or religion. Mental health was assessed on the basis of subjects’ risks for developing significant anxiety or depression (i.e., becoming a clinical ‘case’) in the previous week, using a clinical interview schedule that gave ICD-10 diagnoses. In addition, they made estimates of the annual prevalence of psychosis in the sample using a psychosis screening questionnaire.
African-Caribbean people were most likely to report racial harassment, followed by Pakistanis and Indians. The risk of psychosis was significantly associated with the experience of verbal racial abuse, physical assaults and work-place discrimination. Experiences of racial abuse (verbal or physical) doubled the risk of psychosis compared with those who had no such experiences. Work-place discrimination was also associated with an increased risk of psychosis, although this was not statistically significant. These relationships were independent of age, gender, occupational and employment status.
In a community study of over 5,600 people in Holland, Janssen et al found the rate of delusional beliefs in people who reported at least one instance of racial discrimination (0.9%) was nearly twice as high as the rate in those who reported none. In addition, 2.7 per cent of those who experienced discrimination in more than one domain showed evidence of delusional beliefs (but not hallucinations). These differences were statistically significant even when other demographic factors were taken into account. These results indicated that ‘… perceived discrimination predicts, in a dose-response fashion, incident delusional ideation’ (Janssen et al: 73).
It is important to be absolutely clear that I am not accusing the authors of deliberately ignoring the importance of black perspectives in their report. Rather, the way in which the report was carried out, the sort of evidence that was adduced, the sources of that evidence, who was involved in decisions about where to search and whose testimonies mattered, meant that it was inevitably flawed from the outset by virtue of the fact that very few, if any, people from black backgrounds were involved in it. I know most of the contributors to the report, and unless I am mistaken, it is clear that not one of them can be described as coming from a non-Western cultural tradition. The report is sprinkled with quotes from survivors / service users about their experiences of psychosis and the help they have received, but again the great majority of these are, as far as I can see, white voices. No reference is made to well-designed studies that have sought out Black people’s experiences of distress and mental health services .
Jayasree Kalathil , the lead author of one of the most recent research reports that deals specifically with the experiences of black women, argues that in terms of social justice, equity and fairness, the report is seriously flawed. In her perceptive account of the launch event, which she attended, she points out that it is simply not possible to uphold the claims that the report is a ‘ground-breaking’ departure that marks a paradigm shift in mental health theory and practice. It may be a paradigm shift but it is one that is of little or no relevance to 14% of the British population. Jayasree writes as follows:
The most obvious of this [problem], to me, was the conspicuous absence of professionals and user/survivors from racialised (BME) communities in the working party and in the invited audience (there were a handful in the audience), and any meaningful engagement with the over 50 years of scholarship about ‘race’/ethnicity and psychiatry – especially around the theorisation and experience of schizophrenia – in the report.
She goes on to question whether the practice of clinical psychology and therapy are just as badly affected by flawed thinking about psychosis as are biomedical diagnoses and practices.
This is sadly ironic given that some of the clinical psychology contributors to the report have written scathingly, and with good reason, about the failure of biomedical psychiatry and psychiatric diagnosis to engage with the contexts of people’s lives.
There is a strong case to be made for the view that if we place the individual’s cultural heritage and identity at the centre of our attempts to help people who experience psychosis and distress, then we will end up with systems of help and support that are fair and equitable for all people, not just the 86% white majority. Doubtless, many will interpret what I have written here as unwarranted criticism of what is undeniably an otherwise excellent report, but the matter of race and culture is vital because the true mark of a democracy is the extent to which it engages positively with its minority groups.
The report comes at a particularly important moment in British culture. Next year we face a general election in which cultural identity is at the heart of a political debate driven by the gold and purple favours of a resurgent, sanitised, political right. Against that context it is especially sad that the BPS/DCP report fails to engage positively with cultural difference in relation to mental health. Perhaps it can go some way to rectifying this by commissioning a report on ‘Race’ and Culture in the diagnosis of ‘psychosis and ‘schizophrenia’, and the impact of these diagnoses on black people, as well as the help and support they are offered?
1. British Psychological Society/Division of Clinical Psychology (2014) Understanding Psychosis and Schizophrenia accessed on 3rd December 2014
2. Bhui, K. & Bhugra, D. (2002) Mental illness in Black and Asian ethnic minorities: Pathways to care and outcome. Advances in Psychiatric Treatment, 8, 26–33.
3. Fernando, S. (1991) Mental Health, Race and Culture. Basingstoke/London: Macmillan/MIND Publications.
4. Sashidharan, S. (1993) Afro-Caribbeans and schizophrenia: The ethnic vulnerability hypothesis re-examined. International Review of Psychiatry, 5, 129–44.
5. Fearon, P., Kirkbride, J., Morgan, C., Dazzan, P., Morgan, K., Lloyd, T. et al (2006) Incidence of schizophrenia and other psychoses in ethnic minority groups: Results from the MRC AESOP Study. Psychological Medicine, 36, 1541–50. doi: 10.1017/S0033291706008774.
6. Davies, S., Thornicroft, G., Lease, M. et al (1996) Ethnic differences in the risk of compulsory psychiatric admission among representative cases of psychosis in London. British Medical Journal, 312, 533–7.
7. Coid, J., Kahtan, N., Gault, S. et al (2000) Ethnic differences in admissions to secure forensic psychiatry services. British Journal of Psychiatry, 177, 241–7.
8. Bhui, K., Brown, R., Hardie. T. et al (1998) African-Caribbean men remanded to Brixton prison. British Journal of Psychiatry, 172, 337–44.
9. Thomas, P. (2014) Psychiatry in Context: Experience, Meaning and Communities. PCCS Books, Ross-on-Wye (see especially Chapter 6, pp 95 – 116)
10. Karlsen, S., Nazroo, J., McKenzie, K., Bhui, K. & Weich, S. (2005) Racism, psychosis and common mental disorder among ethnic minority groups in England. Psychological Medicine, 35, 1795–803. doi: 10.1017/S0033291705005830.
11. Janssen, I., Hanssen, M., Bak, R., Bijl, V, De Graaf, R., Vollebergh, W. et al (2003) Discrimination and delusional ideation. British Journal of Psychiatry, 182, 71–6.
12. SCMH (2002) 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.
13. Walls, P. & Sashidharan, S. (2003) Real Voices – Survey findings from a series of community consultation events involving black and minority ethnic groups in England. London: Department of Health.
14. Kalathil, J., Collier, B., Bhakta, R., Daniel, O., Joseph, D. & Trivedi, P. (2011) Recovery and Resilience: African, African-Caribbean and South Asian women’s narratives of recovery from mental distress. London: Mental Health Foundation.