One cannot deny that when depression or anxiety is talked about with first generation Asian migrants, a look of bewilderment fills their faces. ‘What is there to be depressed about?’ is often the question asked. ‘What is this depression anyway – we never heard of it back home’ is often the follow-up remark.
It is widely accepted that mental health needs are not generally identified or acknowledged within Asian communities living in Great Britain. I know this is a contentious statement, and perhaps a gross generalisation. However, as you read this article things will become clearer.
I can't count the number of times I've been in discussion with elders from Indian, Pakistani and Bangladeshi communities, and they have struggled to understand mental health without stigmatising those who suffer, or making absurd commentaries about 'weak mindedness' or 'character'. Terms such as 'mad' and 'crazy' (of course in the Punjabi, Hindi or Urdu vernacular - e.g. 'pagaal' ) are commonplace, in these discussions. It often develops into an analysis of the fact that 'our community' now has nice homes, good food to enjoy and adequate means of transport – with so many facilities and comforts, how can anyone feel depressed?
Perhaps it’s something to do with the fact that when people of my parents’generation moved to England in the 1960's and 1970's, they came out of economic need - often, dire poverty. Back ‘home’, there were daily struggles for many with basic day to day needs, but families stayed close together, and made the most of what little they had. Again, I appreciate this is generalising - it may not be the case for all migrants, but of the many hundreds I have spoken to and observed, most acknowledge they came for work, and laboured hard in factories and manual job roles in order to send money home (to their native country). Many had left their wives and children, just to earn a living.
When food, clothing and shelter are not guaranteed or inconsistently available, there is arguably little time to reflect on emotional needs. I am not talking about missing a meal - but literally eating, and not knowing where the next meal will come from. Navel gazing would not fill anyone’s stomach, and survival depended on hard work. In this context, we should not be surprised that the community is confused about mental health, when so much is available and provided for.
The resilience of these individuals also needs mention - there are countless stories of young men in their late teens or early 20's, coming to the UK with £5 in their pocket and one small bag of belongings. Through sheer graft, they now contribute hugely to the British Economy - in 2007, a University of Surrey study reported that Asian owned businesses in London had a turnover of over £60 billion, and had seen growth in wealth of 68% over the previous 7 years, compared UK GDP at 23%. For a small minority of the population, this is astounding.
Whilst certain members of the Asian community may hold back from recognising mental health needs, there is often also a prevalent belief amongst support professionals (such as GP’s, health visitors and so forth) that Asians function well in society and have few emotional adjustment problems. These beliefs may stem from the fact that Asians have tended to live in supportive enclaves and extended family networks. Furthermore, they have tended to gain support from religious networks, and have generally enjoyed good educational and occupational status.
Then, we have the research evidence which indicates that some Asian groups, particularly those of Indian and Chinese ethnicity are relatively psychologically robust. In April 2010 the Care Quality Commission’s (CQC) review of the final ‘Count Me In’ Census showed that whilst admission rates to mental health hospitals were two times or more higher than average among Black or mixed race (White/Black) patients, admission rates were consistently lower than average among the Indian and Chinese groups, and about average in the Pakistani and Bangladeshi groups. A briefing paper by MIND, written to inform commissioning groups in 2013, suggests Indian, Bangladeshi and Chinese people having consistently low referral rates to Crisis Resolution and Home Treatment teams.
These findings beg the question - are Asians bewildered by talk of mental health problems because they really don’t experience such needs? Are Asians underrepresented in mental health services because they have less cause to use them? I seriously doubt it. Stress and emotional fatigue are universal experiences, and a growing trend in today’s individualist world, where there is greater uncertainty, more virtual relating than actual, and financial burdens that the state has passed to society in such a way that the gap between rich and poor is growing. What’s more, we all need to feel secure, loved and appreciated. We all have some degree of hang-up about being approved of, being seen to be successful and well-balanced. Where these needs are present, anxiety and depression cannot be far behind.
In reality it is difficult to evaluate the extent of psychological needs in any group. Inpatient status at a mental health hospital or indeed referral rates to outpatient mental health services are very blunt instruments for measuring rates of psychological distress in populations. Not all individuals who are distressed seek help, or gain appropriate referrals to secondary agencies. Furthermore, to measure prevalence we need precise operational definitions of the disorder concerned, together with valid measures for its ascertainment. We also need to define the population to be studied. Clearly, there is potential for methodological shortcomings at each level described, and prevalence statistics need to viewed with extreme caution. Disorders can be difficult to define within cultures, let alone across them. In respect of ‘depression’, Rack (1982, p.105) states that “reports of the incidence of depression in various cultures are unreliable”, and contends that depressive illness exists wherever it is looked for, if the questions are rightly framed.
There may be various factors which influence the degree to which immigrant groups consult services for help. These may be intrinsic to the community (e.g. alternative sources of support, shame associated with mental health problems, differential means of expressing and dealing with distress and so on). There may also be other, more external factors (e.g. service related barriers, difficulties that medical practitioners may have in detecting mental health concerns etc.). For example, a report by MIND (2013) highlights issues with communication as a critical component in mental health treatment and support, especially when there is a language difference and lack of interpreting services on hand, as well as a lack of psychological therapy in the person’s own language. This is a growing problem for the UK to contend with, especially when we consider the plight of refugees and asylum seekers, who increasingly form part of the black and minority ethnic landscape in parts of the country.
It is known that Asians, particularly from the Indian subcontinent and first generation migrants to the UK, consult alternative practitioners (e.g. Vaids, Hakims etc.). In a study by Aslam, the work of a visiting Hakim was followed over a four day period in London. 96 patients were seen, some travelling from great distances, and according to the classification system of the Hakim a range of complaints were ‘diagnosed’. Mental difficulties were diagnosed most frequently, followed by nutritional, circulatory and genito-urinary complaints. It is not unlikely that some of the patients had psychological components to these conditions. As Rack puts it, “in respect of mental illness, the evidence suggests that Hakims deal with a great many cases of neurosis and psychosomatic illness, in which communication and cultural sensitivity are vital”. I would suggest therefore, that Asians do indeed suffer mental health needs, but sometimes require a certain cultural sensitivity and approach that helps to recognise or talk about them. Support professionals also need training in how to ask the right questions, and understand the particular ways in which Asians express their needs. There is now growing research, especially within Asian communities who have been born and raised in the UK, that the gap in identification of needs and appropriate help seeking is improving. My concern is for the older generation of Asians now entering retirement, often having worked excessively long hours and feeling redundant in their role. They may not have the language or resources to discuss what they are experiencing should their mood drop or stresses rise. Health services need to be especially thoughtful about considering their needs.
If this write-up has been of interest, do look out for others in my series on mental health within Asian communities. If you are seeking support for someone you love, but they are struggling to understand what is happening because of cultural or language barriers, do get in touch to access assessment and therapy that is more sensitive to these needs.
Dr Bobby Sura BSc Hons, PG Dip, DClinPsy, CPsychol
Consultant Clinical Psychologist and Psychotherapist
Dr Bobby Sura is a Consultant Clinical Psychologist specialising within the field of lifespan and family based mental health needs. He has over 20yrs NHS experience and 13yrs in the private sector, being the founder of Clinical Psychology Direct and Director for Solihull Well Being Clinic. Dr Sura is Chartered with the British Psychological Society (BPS), Division of Clinical Psychology (DCP), Health and Care Professions Council (HCPC) with eligibility for registration with the United Kingdom Council for Psychotherapy (UKCP) and Association of Family Therapy (AFT).