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About this book

This powerful text offers a unique analysis of the impact of race and culture on contemporary issues in mental health. Drawing on extensive international experience, Fernando challenges the traditional ideas that inform practice in clinical psychology and psychiatry in order to promote new and alternative ways of thinking. Covering both theoretical perspectives and practical implications, this insightful text discusses perceptions of ethnicity and identity, compares practices around the world and looks at racism in mental health services.

This fully revised, expanded and updated edition of a seminal text offers students and practitioners alike a comprehensive and reliable study of both western and non-western psychiatry and mental health practices.

Table of Contents

Introduction

Introduction

Abstract
At the start of this millennium WHO (2000) defined the objective of good health as twofold: ‘the best attainable average level — goodness — and the smallest feasible difference among individuals and groups — fairness’ (p. xi, italics in original). Eight years later, WHO (2008), stating that ‘mental health is crucial to the overall well-being of individuals, societies, and countries’, points to the negative cycle between poverty and mental ill health (p. 6). The issue of fairness is about justice and human rights not just individual rights as embodied in current international conventions — the United Nations first adopted its Universal Declaration of Human Rights in 1948 (United Nations, 1996) and the European Community adopted a similar convention in 1950 (Council of Europe, 2003) — and in British law as the Human Rights Act (1998), but rights of groups of people, communities, cultural groups, nations, or whatever, who wish to maintain their ways of life, their cultures, their inheritance and their futures; and the rights of groups of people seen as ‘races’ covered, for example, in British Race Relations Acts of 1968 and 1976 and the Race Relations (Amendment) Act 2000.
Suman Fernando

Theory and Tradition

Frontmatter

Chapter 1. Race and Culture; Ethnicity and Identity

Abstract
The discourse around race and culture in the mental health field has undergone complicated manoeuvres over the past twenty years, bringing to prominence two ideas related to race and culture, namely ethnicity and identity. This chapter discusses all four concepts before exploring the meaning of ‘community’ in relation to the primary concepts of race and culture and examining racism both in historical and current perspectives, mainly from a practical point of view.
Suman Fernando

Chapter 2. Traditional Approaches to Mental Health

Abstract
Traditions, like cultures, are not fixed entities. But as in the case of culture, exploring established customs, ways of thinking and attitudes of mind — all of which are subsumed in the concept of a tradition — is a useful approach to understanding current realities.
Suman Fernando

Chapter 3. Background and Culture of Psychiatry

Abstract
Many ideas in current psychiatry can be traced back to Greek roots (Simon, 1978): Methods of dealing with deviancy were foreshadowed when Plato (427–348 bc) proposed in his Laws that atheists, whose lack of faith seemed to arise from ignorance rather than malice, should be placed for five years in a sophronisterion (house of sanity). Plato talked of unconscious motivation and the interpretation of dreams; and in The Republic he divided the mind into three parts likened to three different kinds of men: the lover of wisdom (philosophus) corresponding to the rational, the lover of victory (philonikos) to the spirited-affective, and the lover of gain (philoker-des) to the appetitive. These ideas led to the concept of mind as being composed of higher and lower parts, the former being rational and aware, the latter being concerned with appetites of the body, somatic sensations and dreaming. Socrates (469–399 bc) saw knowledge as dormant in the soul and talked of unconscious processes. Hippocrates (400 bc) described mania, melancholia and ‘phrenitis’ — mental confusion — possibly as tendencies rather than illnesses with accounts that stand up well when compared with descriptions of illnesses with similar names in present-day biomedical psychiatry. It is the Hippocratic tradition that continues in the current system of western medicine — or allopathic medicine — of which psychiatry is a part, except that Hippocratic explanations for diseases were based on humoral theories while modern aetiological models attempt to find specific causes for diseases. But Greek ideas did not come to western civilization unchanged — they came via Islamic medicine and Arabic literature.
Suman Fernando

Chapter 4. Racism in Psychiatry

Abstract
When the basis of psychiatry was being laid down in the mid-nineteenth century, psychiatrists and psychologists, like others around them, had very definite ideas on which races were civilized and which were not. A paper published at the time in the Journal of Mental Science, which later became the British Journal of Psychiatry, by a former physician superintendent of Norfolk County Asylum (England) who was working in Turkey referred to that land as ‘a country which forms the link between civilization and barbarism’ (Foote, 1858, p. 444); in the same journal, another eminent British psychiatrist, Daniel H. Tuke (1858), denoted Eskimos, Chinese, Egyptians and American blacks as ‘uncivilized’ people, contrasting them with Europeans and American whites referred to as ‘civilized’ people, but with a grudging reference to China as ‘in some respects decidedly civilized’ (1858, p. 108). The description of Africans as ‘child-like savages’ by Arrah B. Evarts (1913, p. 393), a physician at the Government Hospital for the Insane in Washington, DC (USA), was typical of opinion among psychiatrists in the USA during the early twentieth century.
Suman Fernando

Chapter 5. Changing Discourse in Mental Health

Abstract
‘Change’ has been a popular cry in the political arenas of both the UK and USA since the mid-2008. However, there is doubt as to whether it is backed up by substance or even the political will. The pressure on psychiatry and style of mental health care in UK to change comes mainly from service users — or as they were called in the 1990s, survivors of the psychiatric system. But it also comes from sections of the general public, especially BME people — or more specifically black people, namely people from African and African Caribbean ethnicities, for the reasons evident in many of the chapters in this book, especially Chapter 7. Western psychology too catches some of the criticism but mainly at an academic level (see e.g., Parker et al., 1995 and Parker, 2007).
Suman Fernando

Chapter 6. Trauma and Post-traumatic Stress; Suffering and Violence

Abstract
‘Trauma’, meaning psychogenic trauma or mental trauma when used in a mental health context, has become a key word in western psychology through which both academic discourse and clinical work approach the human experience of events involving violence and their aftermath. Originally, trauma was purely about physical wounds but ‘was extended, via analogy, to include cognitive-emotional states that cause psychological and existential pain and suffering’ (Young, 1997, p. 246, italics in original). But in many ways, the concept of trauma has been widened ‘to cover a vast array of situations of extremity and equally varied individual and collective responses’ (Kirmayer et al. 2007a, p. 1). It has even been used to highlight current racism in the USA against African Americans by calling its impact on their minds passed down the generations as amounting to an illness of ‘post traumatic slave syndrome’ (DeGruy Leary, 2005, title page).
Suman Fernando

Practice and Innovation

Frontmatter

Chapter 7. Application of Psychiatry: Bias and Imperialism

Abstract
The application of biomedical psychiatry in multicultural societies and across the world raises several issues around validity. Also, the importance of racial bias in the practice of psychiatry in multiracial settings is often ignored except when obvious — as it was in the case of South Africa in the days of apartheid (Jewkes, 1984; WHO, 1977). This chapter attempts to explore these problems.
Suman Fernando

Chapter 8. Asian and African ‘Therapy’ for Mental Health

Abstract
Although biomedical psychiatry within the overall aegis of western — sometimes called ‘allopathic’ — medicine is now practised worldwide, other indigenous systems of what are sometimes called ‘folk-ethnopsychiatry’ by anthropologists (Blue and Gaines, 1992) still persist in many parts of the world, although more so in non-western countries than in the West.
Suman Fernando

Chapter 9. Mental Health in Low- and Middle-Income Countries

Abstract
In the post-colonial era when the cold war was in full swing the term ‘third world’ was given to countries that did not fall into one or other power block. Then, as economic development was seen as the way forward for all countries, the world was roughly divided into ‘developed’ and ‘underdeveloped’/‘developing’ nations. More recently a classification has been introduced by the World Bank of categorizing countries on the basis of gross national income (GNI) per capita, calculated using the World Bank Atlas method (http://www.worldbank.org): Using 2007 GNI per capita incomes, low-income countries (LIC) have $935 or less; lower middle-income countries (LMC) $936–$3705; upper middle-income countries (UMC) $3706–$11,455; and high-income countries (HIC) $11,456 or more (World Bank, 2008). Examples of the groupings based on GNI are as follows:
  • LIC includes Afghanistan, Bangladesh, Cambodia, Congo Republic (Zaire), Haiti, Kenya, Nepal, Pakistan, Tanzania, Uganda, and Uzbekistan.
  • LMC includes Albania, Angola, China, Guatemala, India, Iraq, Nicaragua, Peru, Sri Lanka, and West Bank and Gaza (Palestine).
  • UMC include Argentina, Brazil, Chile, Czech Republic, Jamaica, Malaysia, Mexico, Poland, Russian Federation, South Africa, Suriname, St Vincent and Grenadines, and Turkey.
  • HIC include Australia and New Zealand, Canada, Germany, Israel, Ireland, Saudi Arabia, Trinidad & Tobago, USA, UK and other West European countries, United Arab Emirates, Qatar, Kuwait.
Suman Fernando

Chapter 10. Mental Health of Refugees in High-Income Countries

Abstract
A major feature of the past two decades has been the massive forced migration of people because of war, natural disasters and poverty, in spite of restrictions enforced on travel across national borders, especially those of countries in the European Union (EU). Today large numbers of people are either ‘internally displaced persons’ (IDPs) or live in foreign countries as ‘asylum seekers’ or ‘refugees’. The United Nations High Commissioner for Refugees (UNHCR, 2008) estimates 51 million IDPs worldwide, 26 million displaced as a result of armed conflict and another 25 million displaced by natural disasters, and 16 million refugees of which about 1.6 million live outside their regions of origin. Although the underlying causes for this massive number of people fleeing from, or evicted from, their homelands are complex — civil war, ethnic conflict, famine poverty and natural disaster — they could be envisaged largely as the legacy of 300 years of European expansion into Africa, Asia and America with its human rights abuses, stealing of property and land, and cultural, political and economic underdevelopment of Asia and Africa, added to by the post-war colonization of Palestine by European settlers and the more recent invasion of Iraq by some western nations.
Suman Fernando

Chapter 11. Prospects for Plurality in Therapies for Mental Health

Abstract
Earlier chapters make the case against applying biomedical psychiatry across the world as a total package; clearly, it would be equally unwise to think that ways of dealing with emotional stress and/or maintaining mental health developed in non-western cultures can be applied in toto outside the cultures that they grew up in. This chapter discusses the transcultural portability of fragments of cultural systems in the shape of what may be called ‘technologies’ concerned with mental health — a term that, broadly speaking, means ‘any tool or technique, any product or process, any physical equipment or method of doing or making, by which human capability is extended’ (Schon, 1967, p. 1); in the context of mental health this refers to ways of handling stress, counteracting what may be conceived as mental illness, and promoting well-being, spiritual development, and recovery from emotional crises. This chapter should be seen as a prelude to Chapter 12 where ideas of unity and amalgamation across racial and cultural barriers are taken further.
Suman Fernando

Chapter 12. Mental Health for All

Abstract
The purpose of the final chapter is twofold. First, it aims to get beyond the long-standing conflict between concepts of cultural relativism and universality in questions of mental health (Chapters 2, 7 and 8), while facing up to the reality of racism, ethnic loyalties and the many social and political issues that complicate the picture. Second, the chapter attempts to develop ways of working with people with mental health problems that have universal applicability, countering the globalization of ideologies around mental health that actually means the imposition of western cultural concepts on the back of what is seen as ‘scientific knowledge’ fed by the power of pharmaceutical companies. It is constructed in four sections, redefining mental illness, restructuring mental health, mental health promotion and developing systems that promote change.
Suman Fernando
Additional information