In previous editions of this book we noted that Irish people in mainland Britain have had high rates of diagnosed mental health problems, despite being English speaking and Caucasian in appear- ance (Sproston and Nazroo 2002; Fitzpatrick and Newton 2005).
Thus when we come to consider the vulnerability of ethnic minorities to mental health prob- lems, the direct social stress of racism elicited by skin colour cannot be the sole variable of explanation. For example, South Asian groups in Britain are all exposed to, and sometimes are individually subjected to, racism in their lives but not all of them have elevated rates of psychi- atric diagnosis.
The Irish in Britain were treated prejudicially for a range of historical reasons, and social rejection and stereotyping of them from the English came in a variety of forms. Moreover, like the Caribbean migrants appearing in England in the 1950s they were forced into poor housing.
In addition, their employment patterns typically involved low pay and this could be an important associated variable to account for raised rates of mental disorder. Earnings were often sent back home creating immediate poverty despite being in employment.
While some migrants are rich, this is rare. Economic migrants by definition are seeking to escape from absolute or relative poverty. Economic migration involves more ‘choice’ than some other social conditions (see below) but it still might reflect psycho-social pressure to escape from native poverty. In the case of the Irish, that pressure was at its most evident in the mass migrations to the UK and the USA during the nineteenth century, because of starvation. The depopulation of Ireland continued until the mid-twentieth century.
And if migration is forced, for example by starvation, warfare or torture, then subsistence exist- ence is typically experienced by those fleeing. Asylum-seeking in these circumstances has become an important social policy question for governments of developed countries in recent decades. It has particular implications for the mental health status of those seeking refuge (Tribe and Patel 2007).
More generally we know that stressful life events impact on mental health. Consequently, forced migration implicates general additive vulnerability factors following the experience of a traumatic event. The latter include the magnitude of the event, its personal meaning to the victim, lack of con- trol over the event, its predictability, its impact on physical welfare, and its diversionary impact on expressed needs or normal expectations in the life course (Dohrenwend 2006).
It is easy to see from this list the cumulative vulnerability for people living in conditions of forced migration. Under conditions of intensifying entrapment in life all people (and other mam- mals) are more and more likely to ‘give up’ and experience ‘learned helplessness’ (Seligman 1975).
Two common outcomes of this social-existential predicament are to become profoundly sad (‘clini- cal depression’) or nihilistic. Brown et al. (1995) discuss these outcomes in relation to self-harm and it can even extend to psychotic escape attempts, such as a black person denying that they are black. Also, especially in those subjected to trauma, there is a constant hyper-vigilance about new stressors, which can be construed as evidence of paranoia by onlookers.
The universal appeal to social causationist arguments just outlined can be tempered by evi- dence of cultural differences. For example, Obeyesekere (1985) notes that in Buddhist cultures suffering and its acceptance are both expected. This could account for why in conditions of
RAcE ANd ETHNiciTy 67
extreme population level trauma (such as genocidal wars in Sri Lanka and Cambodia) depression does not have the same meaning as it does, say, in the USA. For this reason, comparative studies of migration and depression imply the need for careful ethnographic consideration (Kokanovic 2011).
Also note the different norms of indigenous adaptation cited in Buddhist Sri Lanka or Cambo- dia and compare them to different norms in receiving countries during asylum-seeking. That clash of norms might itself generate personal confusion, especially when receiving mental health profes- sionals deploy assumptions about universal criteria of psychological abnormality. (We discussed this contention in relation to current arguments about ‘global mental health’ and Watters’ thesis about ‘the globalization of the American psyche’ in Chapter 1.)
And where social causationist arguments are developed about migration and culture then this introduces another factor of amalgam social stress: fear and dislocation combined with poverty.
With this subjectively experienced amalgam vulnerability, there comes a form of structural divi- sion, as migrants become identified by others in class terms because of their typical poverty: a process of social construction then which is economically driven (Miles 1996). We can see then that the process and outcome of migration and its health impacts have both subjective and objective aspects.
When migrants finds themselves in a new setting it will be culturally unfamiliar. They may seek social support in areas containing those of a similar background. This is a familiar scenario in most developed countries that have had spates of immigration, such as the UK, Australia and the USA. If those localities are poor then this increases the risk of all forms of mental disorder. To complicate matters, if people with pre-existing mental health problems live in unfamiliar areas with low ethnic density then this increases the chances of relapse (Karlsen et al. 2005). Thus direct environmental risks to migrants come in more than one guise.
The children of migrants may retain levels of disadvantage in a number of ways including con- tinuing prejudice, poverty and identity confusion. In the latter regard problems of the ‘post-colonial identity’ can affect those now being born and living at home in the land that historically colonized that of their ancestors (DelVecchio et al. 2008). Racial harassment and these post-colonial impacts may persist for several generations after migration, which can translate into psychological distress (Karlsen and Nazroo 2002).
Discussion
There is an alternative way of viewing the debate on race and mental health, which goes beyond attempting to identify causal factors in the high incidence of mental illness among BME groups or pinpointing prejudicial labelling practices. This focuses on the discourse of race and psychiatry.
As Foucault (1965) has argued, we live with an ingrained predisposition to view madness as essentially ‘other’. The use of the Victorian asylums for warehousing the insane was a mechanism for bringing about a break in the dialogue between reason and unreason on the one hand, and society and the disturbed on the other. In our contemporary era, where large mental hospitals are now extinct, the narrative of loss and difference is preserved in the status of becoming a patient.
This is clearly expressed by Barham and Hayward (1991: 2), who note that people who receive a diagnosis of schizophrenia tend to be viewed as ‘lost to the disorder’. They become a stranger to themselves and others. They become alien:
Schizophrenia is more than an illness that one has; it is something a person is or may become.
The person who has suffered a schizophrenic illness is someone in which a drastic rupture has been effected in the continuity of his or her biography . . . some schools of thought, we discover, do not accept there is an ‘after’ with schizophrenia, only a ‘before’.
68 A Sociology of MENTAl HEAlTH ANd illNESS
The use of the English word ‘alien’ to describe an outsider or foreigner resonates with the early nineteenth-century use of the term ‘alienist’ to describe an expert on madness. This notion of ‘oth- erness’, which characterizes the discourse on psychosis, fits well with a new type of racism. The latter is preoccupied with who should be included or excluded from the mainstream of society:
The new racism is primarily concerned with mechanisms of inclusion and exclusion. It speci- fies who may legitimately belong to the national community and simultaneously advances reasons for the segregation or banishment of those whose ‘origin, sentiment or citizenship’
assigns them elsewhere.
(Gilroy 1987: 45) Within this discourse, people from black and ethnic minorities are identified as an alien force responsible for national decline and social disorder. While the old racism, underpinned by eugen- ics, proposed sterilization and extermination, the new racism suggests banishment and exclusion.
In the context of the British historical legacy of colonialism, the debate on race and madness may be seen as central to the inner workings of this ‘new racism’. This chapter has reviewed the evidence on the mental ill-health of groups of people, who are the legacy of British colonialism as ex-slaves, servants, imported service labour and, in the case of the Irish, have been implicated in a post-colonial armed struggle.
Academic and psychiatric literature alluding to race accentuates those mental illnesses which imply a threatening and hostile alien presence. Professional and academic texts then become part of a wider discourse about a threat to a traditional social order. This threat includes terrorism, non- Christian faiths, alien diet, arcane cultural norms, violent street crime, illicit drug use and so on.
These images may then reinforce, or even be used to justify, English racism and endorse processes of segregation, exclusion or banishment.
Mental health and anti-terrorist legislation may be conceptualized as being part of what Althusser (1971) called the ‘repressive state apparatus’, which allows for preventive detention with- out trial, and the segregation or exclusion of threatening or undesirable ‘others’. Banishment and exclusion can be reinforced by powers under mental health law to repatriate mentally ill aliens.
Entry to the country on psychiatric grounds can also be banned under immigration legislation (Rogers and Pilgrim 1989).
However, the legitimacy of repatriation has declined in a context where a growing proportion of black people are British-born. It has become logically untenable. British-born black people have no identifiable nation state to which they can be banished (whether it be to the Indian subcontinent or the Caribbean of their parents, suggested only now by neo-Nazi groups in Britain). Likewise, Europeanization has ensured that rights of residence will be protected for people from any part of the British Isles.
Coercive psychiatry, as part of the wider repressive state apparatus, offers itself as a post- colonial, Europeanized alternative to repatriation. Ideas about banishment to another country can be replaced by the mechanisms of exclusion and control afforded by the mental hospital, prison and physical treatments. Not only are black and Irish people more likely to be incarcerated in locked facilities, and restrained using physical treatments, they are concomitantly represented as the ‘other’ in the texts and practices of academics and mental health professionals.
Most of what is summarized in this chapter is part of a discourse in which threat predomi- nates, not distress. For example, compared with the extensive psychiatric literature on com- pulsorily detained African-Caribbean men, there is relatively little to be found on the sadness and despair of Asian women living in the community (Beliappa 1991; Fenton and Sadiq 1991).
Ironically, this picture of differential attention is reinforced by some critiques that concur with our points here about repressive control in a post-colonial context. For example, Fernando et al. (1998) provide an elaborate and sophisticated critique of post-colonial psychiatry.
RAcE ANd ETHNiciTy 69
This chapter has summarized arguments and evidence about the mental health of African- Caribbean, Asian and Irish people in Britain. It has drawn attention to methodological problems of interpreting evidence about over-representation and discussed the errors of Anglo-American psychiatry using a diagnostic approach that is ill suited to people from black and ethnic minority populations. At the time of writing, the challenge of understanding the impact of post-colonial con- ditions upon formerly colonized groups of people, be they black or white, has become complicated by new migration patterns.
Asylum seekers and refugees are now coming to Britain often with experiences of recent trauma. Sociological accounts of this group of people are now invited to add to the literature on those once colonized by Britain. This is likely to produce different sorts of mental health profiles for these newcomers. In other words the mental health of migrants is determined both by their departed country of origin and by the conditions awaiting them in their ‘host’ country.
Questions
1 What factors need to be considered when understanding the relationship between race and health?
2 discuss the evidence about the psychiatric treatment of African-caribbean people in Britain.
3 What factors might account for the over-representation of irish people in psychiatric admissions?
4 What problems are highlighted for psychiatric knowledge by the ‘somatization thesis’?
5 discuss ways in which psychiatric services could improve their response to Asian people.
6 discuss the role of racism in the creation of mental health problems and the character of psychiatric services.
For discussion
consider the ways in which your background has influenced your views about mental health in your own racial group and in that of others.