Search

Colonial thinking runs deep in psychiatry. Recent anti-racist statements from the APA and RCPsych are to be welcomed. However, we argue that if it is to really tackle deep-seated racism and decolonise its curriculum, the discipline will need to critically interrogate the origins of some of its fundamental assumptions, values and priorities. This will not be an easy task. By its very nature, the quest to decolonise is fraught with contradictions and difficulties. However, we make the case that this moment presents an opportunity for psychiatry to engage positively with other forms of critical reflection on structures of power/knowledge in the field of mental health. We propose a number of paths along which progress might be made.

The first part of this chapter explores the origins of ‘race thinking’ in European culture and literature; and then outlines how this led to racism as a dominant ideology in European culture with which to explain diversity of human physical appearance and cultural differences. It describes how race-based slavery (the white-on-black Atlantic slave trade and the plantation cultures of America and the West Indies) and subsequent race-based colonialism established racism as an important part of Western culture over the next 300 years. The second part of the chapter traces the emergence of (Western) clinical psychology and psychiatry (the main ‘psy’ disciplines), as they developed in tandem, through a study of madness in a positivist framework of the post-Enlightenment thinking of the seventeenth and eighteenth centuries. The chapter discusses the confinement of the ‘mad’ and the construction of mental illnesses; how an earlier notion of a positive value of non-reason (of ‘mad’ people) changed to one where madness was seen as ‘illness’; and then how the ‘illness model’ was applied to explain the causes of a variety of human problems, leading finally to the biomedical psychiatry of today. It uses a table listing historic events against events in the development of the ‘psy’ disciplines to illustrate how racism permeated those disciplines.

This chapter considers the overt, unashamed nature of white supremacist thinking that characterised the Victorian age and the years leading up to it, as European power came to dominate most of the world. It traces how racist thinking carried over to become a driving force in the colonial project in Asia and Africa, following on the tradition set during the era of the Atlantic slave trade. Thus racism informed the work of psychologists and psychiatrists during the latter part of the nineteenth and at least the first half of the twentieth centuries, persisting to the present in a variety of ways. The chapter covers ways in which race matters were dealt with in nineteenth-century sociology, psychology and psychiatry. It describes the intimate connections between eugenics and psychology, and the racist ideologies evident in the work of eminent psychiatrists and psychologists. Examples are given of race-specific (mental) illnesses diagnosed among enslaved Africans and racist theories about racial diversity of mental health and mental illness, especially the excessive labelling of black people with the schizophrenia diagnosis.

PurposeThe purpose of this survey was to describe the impact of the diagnosis of schizophrenia on the lives of people who receive the diagnosis.Design/methodology/approachThe authors designed a questionnaire to investigate attitudes to and experiences of the diagnosis of schizophrenia. After a pilot study, they made the questionnaire available online and, through a network of service user and other organisations, solicited responses.FindingsOf the 470 responses, 27.4 per cent were from service users. Content analysis of their responses revealed three main categories: concern with the consequences of the diagnosis and its negative impact on their lives, the life contexts of individuals before receiving the diagnosis, and concerns with medication and treatment. This paper deals with the first two.Research limitations/implicationsIt is impossible to generalise the results of this survey because respondents self‐selected, and thus might be expected to have strong feelings against (or for) the diagnosis of schizophrenia.Practical implicationsThe diagnosis of schizophrenia in this sample had devastating negative implications. It was experienced as harmful and stigmatising. Very few people understood their experiences as a biomedical disorder.Social implicationsA gulf exists between the experiences of people diagnosed with schizophrenia and the concerns of academics and others currently involved in debates about the merits of different systems of diagnosis.Originality/valueThis survey is valuable because it draws attention to experiences of diagnosis that are easily lost in the storm of academic controversies about diagnosis in psychiatry.

What makes a good psychiatrist? What particular skills are needed to practice a ‘medicine of the mind’? Although it is impossible to answer such questions fully we believe that there is mounting evidence that good practice in psychiatry primarily involves engagement with the non-technical dimensions of our work such as relationships, meanings and values. Psychiatry has thus far been guided by a technological paradigm that, although not ignoring these aspects of our work, has kept them as secondary concerns. The dominance of this paradigm can be seen in the importance we have attached to classification systems, causal models of understanding mental distress and the framing of psychiatric care as a series of discrete interventions that can be analysed and measured independent of context. 1 In recent years this Journal has published a series of editorials arguing that the profession should adopt an even more technological and biomedical identity, and that psychiatrists should focus on their mastery of technology to allow progress in the development of brain research, genetics, pharmacology and neuroradiology. 2–4 These resonate with calls in North

In multicultural environments like the US, Canada, and the UK, mental health care systems must serve the needs of increasingly diverse populations. Yet, our capacity to do so is affected by systemic and institutionalized racism that has affected psychiatry and mental health treatment since its inception. This review of a history of racism and its influence on the models we use to treat racial and ethnic minority people raises possibilities of how a contemporary anti-racist mental health approach can address contemporary understandings of race, ethnicity, and culture.

There are several issues to be faced in developing mental health services in South Asia if they are to be culturally and socially appropriate to the needs of the communities in the region. The meanings of mental health relevant to culturally appropriate service development can be obtained by exploring local notions of well-being, systems of care available to people and current practices among those seeking help for mental health problems. Participatory research carried out in communities in Sri Lanka affected by prolonged armed conflict and by the 2004 tsunami clarified the nature of well-being as perceived by communities themselves. Subsequent development of mental health services for Sri Lanka can be based on community consultation, using methodologies and interventions that involve the participation of the communities and their local institutions, and adapting relevant western approaches to the Sri Lankan context.

This paper reports findings of a study that was undertaken as a part of a wider programme of research and capacity building in Sri Lanka. The analysis of individual aspects of well‐being and how they had been affected by displacement provides a basis for the planning of interventions by helping agencies, and for training people who work with refugees.

Mental health service provision varies enormously across the world and faces major challenges, largely determined by the contexts in which it functions. A variety of services exist side by side in low‐income countries. They include services provided in the statutory and private (fee‐paying) sectors, therapies provided by physicians working within indigenous systems of medicine, healing provided at religious locations and services provided by non‐governmental organisations. This paper provides a brief survey of some recent literature on mental health in low‐income countries and goes on to describe a few examples of innovative projects in these countries. The paper concludes by outlining some of the challenges faced by these countries in providing services in the modern world.

The concept of globalization has been applied recently to ways in which mental health may be developed in low- and middle-income countries (LMICs), sometimes referred to as the 'Third World' or developing countries. This paper (1) describes the roots of psychiatry in western culture and its current domination by pharmacological therapies; (2) considers the history of mental health in LMICs, focusing on many being essentially non-western in cultural background with a tradition of using a plurality of systems of care and help for mental health problems, including religious and indigenous systems of medicine; and (3) concludes that in a post-colonial world, mental health development in LMICs should not be left to market forces, which are inevitably manipulated by the interests of multinational corporations mostly located in ex-colonizing countries, especially the pharmaceutical companies.

As psychiatry has developed it has proved to be susceptible to the influence of contemporary social and political mores. With its origins in nineteenth-century Europe, psychiatry evolved as an ethnocentric body of knowledge, the vehicle of implicit and overt racism. Originally published in 1988 this author, however, saw no reason why the contemporary psychiatrist should not challenge this ethnocentrism. He provides a critical account of the development of psychiatry in relation to its cultural context and then examined contemporary practice of the time in the light of this development. Throughout, the book is informed by an awareness of issues of race and culture and of their difficult interactions, the author emphasising both the frequency of racist attitudes and the very real cultural distinctions in our society, distinctions that can be used to mask what are actually racist sentiments. What emerges is not just a plea for an anti-racist, culture sensitive psychiatry, but a blueprint for how this can be brought about. He argued that the shift towards community work and social psychiatry could reorientate the profession by confronting it with its social setting and responsibilities. This book represented a significant contribution to this literature for all mental health professionals and social scientists with an interest in this field at the time; the author has gone on to write many more.

The topic of mental health development in low- and middle-income countries (LMICs) is complicated: They are largely non-western in cultural background (see Chapter 1 for discussion of culture); many were colonized by western powers in the past (see Chapter 5 for discussion of colonial psychiatryt) and some still struggle with postcolonial problems resulting in civil conflict, not to speak of neo-colonial economic domination (see Chapter 8); and, on the whole, they have a multiplicity of fields where development is required. In reality it is artificial and probably not all that productive to separate ‘mental health’ development from development in general. It is important to keep in mind too that the language of ‘mental health’ and ‘mental illness’ that we use in discussing development is embedded in western culture, the concepts themselves being derived from the study of madness as understood in the West, and so the discourse on ‘mental health’ is beset by problems of cultural translation and mistranslation (Chapter 2). Finally, unlike ‘development’ during colonial times (when the benefit was mainly for the colonial power concerned), development in a postcolonial world must be primarily for the benefit of local people in LMICs and geared to their cultural and social expectations. Yet, I concede that compromises may be required in the real world, mainly because some of the resources (in the form of investment) and some of the know-how for development has to come from high-income countries (HICs) and also because there is undoubtedly much that LMICs can learn from the way things are done in the developed world in many fields of health; for example, in general medical services such as HIV and tuberculosis.

According to historian Edward Shorter (1997): ‘Before the end of the eighteenth century, there was no such thing as psychiatry’ (p. 1), meaning that doctors who cared for inmates of institutions to house people deemed to be ‘insane’ (which had existed in Europe from the middle ages) did not work to a medical system as such but were purely custodians. But, Shorter ignores the medieval maristans (Islamic hospitals) of North Africa and Spain referred to in Chapter 2, where organized medical treatment in the (Greek) Galenic tradition that was incorporated into Islamic medicine was provided for the patients, who were diagnosed mostly as suffering from melancholia (Dols, 1992). Also, Shorter seems to discount the work of Pinel in France in the 1790s, where asylum inmates were given psychological treatment (see below). Unfortunately, with the break-up of the Islamic empire and the consequent deterioration of the maristans, anything resembling an Islamic medical system (for insanity as an illness) seemed to have disappeared, except for bits that survive in the unani tradition of India and western Asia (‘the near-east’ of Europeans); and the work of Pinel lost its impact in the French asylums as the gains of the French revolution dissipated.

It is difficult to set mental health and ill-health (as understood today in the English-language literature and discourse) in a proper historical context worldwide because the language of mental health and illness has come about in a very limited part—primarily European—of a culturally diverse universe with its medical and psychological traditions being influenced very much by (western) psychiatry (see Chapters 2 and 3). In other words, the discourse in the field of mental health is articulated in the form of concepts mostly embedded in Euro-American psychiatry. The concepts around mind, illness and health in other cultures—those of the Majority World—that would approximate, or be similar to, ‘mental health’ and ‘mental illness’ (as understood in the language of psychiatry) are often very different (Chapter 2). As a result, it is not easy to fathom what exactly was going on in the past, nor indeed the present situation, vis-a-vis ‘mental health’ in non-western low- and middle-income countries (LMICs)/the Global South (see ‘Introduction’ for use of language), since, in these non-western cultures, what is seen as ‘mental health’ in Anglo-American English is often not articulated in the language of health and ill-health alone, but mostly in language applicable to social relationships, religion, ethics, philosophy/spirituality or just ordinary non-technical everyday terms.

Health, it is sometimes said, is political because ‘like any other resource or commodity under a neo-liberal economic system, some social groups have more of it than others … its social determinants are amenable to political interventions … [and] … power is exercised over it as part of a wider economic, social and political system’ (Bambra et al., 2005, p. 187). The political nature of health is nowhere more evident than in the case of mental health since the very concept ‘mental health’ is somewhat removed from other aspects of ‘health’; it lacks objective criteria for identifying deviation from health into ‘illness’ rendering psychiatric diagnoses scientifically invalid and of doubtful utility (Chapter 6); and it is strongly dependent on how ‘mind’ is understood, what ‘mental’ actually means, and the variation of this meaning across cultural traditions (Chapter 2). In fact, it would seem that the promotion of ‘mental health’ in many societies would be better served if discourse focuses primarily on its social, psychological and spiritual ingredients, rather than (as if often the case) its medical dimension. Recent focus at the World Health Organization (WHO) on ‘social determinants of health’ (see below) seems a very positive sign because follow through on addressing the problems in the social dimension of health worldwide should have far reaching improvements in social conditions and well-being all round and greater sense of fulfilment for people, both as individuals and communities.

The concept of madness is evident in all human cultures and may be as old as mankind itself (Porter, 2002). However, the talk of mental illness and mental health is relatively recent. Every cultural tradition includes a concept of illness (McQueen, 1978), and often of health meaning freedom from illness, but what illness means and what health means vary across cultures. However, concern with illness is universal (White, 1982), and illness is usually dealt with by medical systems, systems of healing and so on. Nevertheless, the medical system in a cultural tradition may overlap in many ways with its religious system or other aspects of society; and the concepts of mind and of matters to do with ‘mental activity’ have generally become entangled with issues about health and illness. Notions around madness, illness/health and the mind that emerged in the post-Enlightenment culture of Europe in the seventeenth century spread from there to North America and other regions where European settlement occurred, finally crystallizing during the eighteenth and nineteenth centuries in a western tradition evident most forcibly in (western) psychiatry. And these ideas, and even the practice of psychiatry, have spread, although so far to a limited extent, in the non-western world too.

As I was completing this book, the newest version (fifth edition) of the Diagnostic and Statistical Manual of Mental Disorders (DSM- 5) (APA, 2013) was published. The opposition to DSM 5 raised the question for the general public: ‘[D]oes mental illness really exist’ (Doward, 2013, p. 1)? And the (British) Division of Clinical Psychology (part of the British Psychological Association—BPS) issued a position statement on psychiatric nosology calling for a change of paradigm in thinking about the Euro-American system of psychiatric diagnosis (DCP, 2013). Although, strictly speaking, DSM merely provides a system of categorization devised in the USA for the USA, its main use being as a reference for insurance companies paying practitioners for providing psychiatric and psychological treatment. This massive volume is recognized now as exercising power across the world in propagating western psychiatry: ‘[T]he political dominance of the US means that, as soon as a mental disorder is named in the DSM, that disorder becomes valid in the eyes of the many’ (Burns, 2013, p. 1).

The centres of research and progress in psychiatric theory and practice from the 1950s onwards were in the US-UK axis, particularly the USA. As the asylums were phased out, the great medication revolution—no less significant than the ‘great confinement [of lunatics in asylums]’ (Foucault, 1967, p. 38) described in Chapter 3—gradually took hold. The end result was that standard psychiatric practice became basically a matter of matching therapy, usually medication, to diagnoses based on nosology agreed in Europe and the USA after the end of the Second World War (WWII)—ICD-6 Classification of Mental and Behavioural Disorders (ICD-6) (WHO, 1948) or Mental Disorders: Diagnostic and Statistical Manual (DSM-I) (APA, 1952). As a psychiatrist in the British National Health Service (NHS) from the early 1960s onwards, I was part of a changing system, working, at first, in asylums, then at a teaching hospital in central London and then in a psychiatric unit in a general hospital and in the adjoining community.

The current system of diagnosis in psychiatry, whereby complex human problems are reduced to reified entities denoting medical illnesses located in the individual “mind”, is value‐laden and likely to be influenced by stereotypes and images of people held in society. The use of psychiatric diagnoses cross‐culturally is problematic. Black British people of African‐Caribbean ethnicity are over‐represented among people given the diagnosis schizophrenia/psychosis. This situation is explicable in terms of cultural misunderstanding coupled with institutional racism. Extending the diagnosis of schizophrenia/psychosis to children and young people by incorporating a category “psychosis risk syndrome” in DSM‐5 would have serious consequences for human rights.

The closure of long‐stay hospitals and the emphasis on community living have highlighted the challenges services face in meeting the needs of some individuals. Government reports since 1990 on services for people with mental health needs, learning disabilities, challenging behaviour and/or criminal offending have recommended community living whenever possible, outlined the characteristics of good services and made suggestions about how these might be achieved (Department of Health, 1992; Department of Health, 1993; Royal College of Psychiatrists, 1996; NHS Executive, 1998). Nevertheless, most health and social service providers still find it difficult to attain the kinds of service proposed and Bouras (1999) recently concluded that this was partly a result of the separation of services for people with learning disabilities from mainstream mental health services. This paper reports the experience of a local service development intervention designed around the needs of this client group.

The validity and utility of psychiatric diagnoses have long been a bone of contention between and within different professional and patient groups. This was clearly shown by the nearly 70 rapid responses to a 2001 BMJ article that proposed that post-traumatic stress disorder was a social construct

In all societies religious healing tends to exist side by side with naturalistic treatment of ailments with medicines, surgery and physical manipulations, but its sphere of influence tends to shrink in the face of secularisation and scientific medicine (Frank, 1963). The question as to whether this is a good thing in the mental health field was implicit in much of the discussion in Part 1 of this book. Scientific medicine is clearly distinct from, and has largely replaced, religious healing in Western countries. But it is different elsewhere. For example, many people, including traditional healers, in India do not distinguish clearly between religious healing and medical treatment, be it that based on traditional systems indigenous to its culture or on Western, scientific medicine. When an average Indian person consults a Western doctor or an Ayurvedic physician, he or she may chose one or other for pragmatic reasons of effectiveness, custom or convenience; in any case, the person may concurrently seek religious healing. Similarly, people in Africa patronise doctors trained in Western medicine and healers practising indigenous systems of medicine simultaneously (Ademuwagun et al., 1979) and, as Ayoade (1979) observes about the Yoruba of West Africa, they make no distinction between ‘magic’ and medicine as therapy for illness.

The boundary between mental health and mental disorder is concerned with the question of normality — a subject of much controversy (Offer and Sabshin, 1966) even within the limited domain of Western psychiatry, without taking on considerations of cultural difference. Sabshin (1967) has described four approaches to the term normality as used by psychiatrists in the United States. These are normality meaning health as the absence of illness, normality as an ideal state of mind, normality as the average level of functioning of individuals within the context of a total group, and normality as a process that is judged by the functioning of individuals over a period of time. Generally, the term is used to mean the absence of illness and/or average. Of course, these ideas need to be seen in context — in this case the context of the American way of life and worldview. Once questions of culture and race are introduced, not only does one need to look at the picture through a perspective of cultural ‘norms’, but the distortion of these cultural norms by racist perceptions inherent in Western thinking has to be corrected. In short, not only do we need to recognise that each culture has its own norms for health, for ideal states of mind and for the functioning of individuals in society, but that these norms are perceived through race-tinted spectacles.

EDITOR,—The paper by Michael King and colleagues1 should be seen in the context of three important issues studied and explored in several publications.2 3 4 1. Concepts inherent in the model of mental illness used in Western psychiatry are unlikely to be meaningful in a crosscultural setting. 2. Neither schizophrenia nor psychosis as illnesses have been validated for use in crosscultural study. 3. The race of …

SynopsisTwenty-two psychiatric patients who committed suicide while receiving hospital treatment or within 3 months of discharge from psychiatric care were studied using general population statistics, a random sample of 100 psychiatric patients and a control group matched individually with the hospital suicides. The rate of suicide among psychiatric in-patients was over 50 times that in the general population. A higher vulnerability to suicide was detected among in-patients (v. other patient groups), men (v. women) and middle-aged patients (v. older and younger patients). Suicides were differentiated from controls in having suffered more losses (P < 0·05), being psychiatrically ill for the first time (P < 0·05), having a past history of deliberate self-harm (P < 0·05), and not receiving a schizophrenic diagnosis (P < 0·02). People with mid-life crises, patients who swing rapidly into depression while receiving treatment, and individuals who are judged to be depressed because of personal problems may carry a particularly high suicide risk during psychiatric treatment.