Improving nuance in South Asian immigrant mental healthcare
Pallavi discusses the ways in which Western approaches to mental healthcare fail to recognise the nuances of immigrant communities, cultures, and conceptions of self.
If there is anything the pandemic has shown us, it is that isolation is exceptionally rattling. A June 2020 survey by the Centres for Disease Control and Prevention (CDC) reported that 40.19% of adults were experiencing depression, anxiety, PTSD, or substance abuse in the United States. This was three to four times higher than the rates reported just the year prior. Thus, the need for appropriate mental health interventions is higher than ever. Neither the effects of the pandemic nor healthcare needs are uniform across populations. Yet, the diagnosis and treatments we assign to these mental health conditions often do not recognise nor appropriately address these differences. While there is some degree of universality in the human experience, there must be greater nuance and understanding in how we provide mental healthcare, especially in vulnerable and underserved populations. To illustrate this need, I will specifically be looking at how mental health is diagnosed and treated in the United States (US) and how this approach often does not work for the South Asian population here.
Image credit: Unsplash
“The need for appropriate mental health interventions is higher than ever. Neither the effects of the pandemic nor healthcare needs are uniform across populations.”
The medical system in the US is ascribed by the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-V). The DSM-V is a collaborative work created by mental health professionals to lay out guidelines for appropriately diagnosing someone with a mental health condition. Anxiety and depressive disorders are among the most common, annually affecting 19.1% and 10.4% of American adults respectively. For a patient suffering from anxiety, the DSM-V lays out symptoms and the level of daily impairment a patient must be experiencing to receive a diagnosis of generalised anxiety disorder (GAD). These include the duration, breadth, and content of anxiety, as well as the presence of somatic symptoms, such as fatigue or restlessness, not explained by a different physiological cause. While the treatment varies across conditions, the overarching principle remains the same: the evidence we have supports a combination of psychotherapy and pharmacotherapy. A patient diagnosed with GAD is likely to be prescribed a selective serotonin uptake inhibitor (SSRI) and is recommended for a therapy programme, such as cognitive behavioral therapy. Although this is considered standard treatment, the success rate of this regimen broadly varies. This model of mental healthcare does not consistently consider that two patients with GAD may have vastly different cultures, values, and stories, and thus may experience their disorders in very different ways. While there are many components missing in this model, I will delve into three that I have found to be largely absent.
“This model of mental healthcare does not consistently consider that two patients may have vastly different cultures, values, and stories, and thus may experience their disorders in very different ways.”
Mental health diagnosis and treatment largely rely on using the individual as the focal point. As a part of the South Asian community, I have felt caught between the Western sense of self that contrasts sharply with the more collectivist ideals that South Asian cultures hold. In South Asian cultures, there is a high degree of interconnectedness between families and communities, spanning generations. Thus, the concept of ‘the individual’ is diluted. There is a protective element here; ideally, the burdens that one person may have to carry will be bolstered by a community. However, in a dysfunctional dynamic, the diminishment of the individual sphere turns into undue burdens forcibly carried by many. This ties in with the idea of intergenerational trauma. Young South Asian Americans today are the grandchildren and great-grandchildren of those who lived to see the end of colonialism in India. Many are children of parents who immigrated to the West, facing poverty, racism, and uncertainty in a new country. These are not easy events for any generation to cope with, let alone within South Asian culture, where traumatic events are not openly spoken about. There is a profound alteration of sense of self that comes with traumatic occurrences, which can be greatly magnified when it occurs within a culture that also de-emphasises the individual. A communal notion of self can also make it difficult for a person to recognise intergenerational patterns that may be harming them. Contingently, a collectivist focus makes it difficult for many South Asians—whether they are from the era of Indian independence or they are influenced by modern-day societies—to buy into a mental healthcare system that places focus largely on the individual.
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“As a part of the South Asian community, I have felt caught between the Western sense of self that contrasts sharply with the more collectivist ideals that South Asian cultures hold.”
Language is another major barrier in providing nuanced mental healthcare. As clinicians, we use terms like “major depressive disorder” and “generalised anxiety disorder” to demystify. These labels make sense for those who work in healthcare, but what do they really mean to individuals who have never heard these terms before? What do they mean to those who do not speak English? The majority of the clinical language used to describe mental health come from a Western context and are amenable to English speakers. As seen by the portrayals in South Asian media, including cinema, a large number of South Asian languages do not use or have words that speak extensively or objectively about mental health. Thus, it becomes difficult for people to be aware of these issues, let alone act against the stigma around them, when there are barriers for communicating about them.
Finally, each community should be framed within the context of how they view the healthcare system. Like many immigrant communities, there is a degree of mistrust regarding healthcare amongst South Asians. Given the rich history of Eastern medicine within the region, there is an ongoing balance between how much trust the community will divvy up between these traditional, generational healing practices, and Western medicine. A 2016 study in BMC Endocrine Disorders looked at South Asian opinions on diabetes medicine and found a prevalent theme of scepticism. Many of those surveyed worried about drug toxicity, drug interactions, appropriateness of their therapies, and more. Doubt in the healthcare system, coupled with the underlying stigma and shame that South Asian communities hold towards mental health conditions, makes it all the more difficult to seek out help. As many South Asian languages do not have words to describe mental health conditions, negative terms end up being used in their place, increasing the shame around these conditions. According to a 2019 review, shame is deeply woven into the South Asian community and acts as a major barrier towards acceptance and treatment of mental health disorders. Stigma also creates a paradoxical problem: although South Asian cultures are largely collectivistic, the shame surrounding mental health is often so potent that any such problems become the individual’s fault. The effects of this can be devastating. Interconnectedness creates an erosion of the sense of self that is not particularly conducive to handling major stressors and mental health concerns.
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“Healthcare workers should be trained to at least seek out context regarding how a culture views the sphere of the individual, and how its people regard mental health.”
Ultimately, these are only some of the barriers facing South Asian immigrant mental healthcare. There are countless other cultures and innumerable nuances that need to be understood in caring for their mental health. It would be impossible to expect public and clinic health providers to be well versed in the struggles of every community. The idea of culturally competent care—which refers to the ability of healthcare professionals to understand, respect, and interact with patients with cultures and value systems different from their own—recognises this. The core principle here is curiosity; healthcare workers should be trained to at least seek out context regarding how a culture views the sphere of the individual, and how its people regard mental health. Care must also be framed within the context of how the culture views Western healthcare as well as the stigmas it holds regarding not only Western medicine, but mental health overall. For an arena as complex as mental health, there are no clear-cut answers. Simply put, nuance is needed to fight our myopia when it comes to sensitive care in immigrant communities.
The health gradient: from a research challenge to a social justice movement
Prof Michael Marmot writes for the Keppel Health Review on why the social gradient still matters and how inequity still plays a role in the determining health outcomes in the heart of our communities.
Professor Michael Marmot writes the foreword for the Gradients issue of the Keppel Health Review exploring his life’s work and how the social gradient is more relevant today than ever.
Image credit: Thor Nielsen/NTNU, CC BY-SA 2.0, via Wikimedia Commons
My involvement in the social gradient in health began as a research challenge. Inequalities in health were not confined to poor health for the poor and reasonable health for everyone else, but health was socially graded: the lower the position in the social hierarchy the worse the health. I made this observation first, in 1978, in British Civil Servants—the lower the employment grade, the worse the health. But we have now seen social gradients in health in most countries of the world where data have been available, whether social position is defined by income, wealth, education, occupation, or degree of deprivation of area of residence. What started with the Whitehall Study of British civil servants is now of global concern.
Accumulating the evidence to explain the reasons for the gradient have led on to a second challenge: to use evidence to formulate recommendations for policy and practice to reduce health inequalities, to level up the gradient. To that end, I chaired the World Health Organisation (WHO) Commission on Social Determinants of Health. In our final report in 2008, we declared: “Social injustice is killing on a grand scale.” Following the global commission, we have had commissions in three of the WHO Regions: Europe, the Americas, and the Eastern Mediterranean; and a series of Marmot Reviews in England. To give a flavour of the evidence, in our English Reviews we have highlighted six domains that explain the social gradient and where action is needed: early child development, education, employment and working conditions, adequate income for a healthy life, healthy and sustainable places and communities, and addressing the social determinants of behaviours. Our most recent report, in June 2021, was “Build Back Fairer in Greater Manchester”.
The gradient addresses one of two common misconceptions about health inequalities, namely that it is really about poverty. Poverty does damage health but so, too, does position in the social hierarchy and the resulting inequalities in the six domains just listed.
The second misconception is that inequalities in health are mainly to do with inequalities in access to health care. Universal access to high quality health services is important, but it is the social determinants of health that are responsible for developing inequalities in health, in the first place. In fact, so close is the link between social conditions and health that we can say that the level of health of a society tells us a great deal about how well, and how fairly, that society is meeting the needs of its members.
The fact that the evidence shows us what needs to be done to reduce health inequalities—levelling up to make the gradient shallower—and it is not done, lends urgency to the calls for action. We need technical solutions, yes, but we need a greater commitment to social justice.
Often, I am asked if I am not frustrated that there seems to be so little action on the evidence. My response is evidence-based. There is huge interest in the topic of social determinants of health and health equity. In Britain, what may have been a disappointing response nationally, is matched by enthusiastic take up in cities and regions across the United Kingdom. Globally, it is the demand from countries that led to WHO Regions convening Commissions, and for countries in those regions working on health equity. It is reasonable to say that what began as a niche research concern has become a social movement.
The black maternal mortality crisis: it’s her problem, it’s your problem, it’s our problem
Oluwaseun reflects on the black maternal mortality crisis in the UK, arguing that to end this injustice we must all evaluate the presumptions and misconceptions that lie behind these statistics and within ourselves.
Content warning: This article explores themes of racism, trauma, and death
Black women are four times more likely to die in childbirth or pregnancy when compared to their white counterparts in the United Kingdom (UK). Last year, that number was five.
As a black woman, I can’t help but feel sickened and exasperated when I see these figures. Why are the odds against us? Is anyone ever going to treat these deaths like the epidemic it is? Is anyone truly willing to address the root cause of this issue? These statistics are not just an unfortunate thing that is happening to people; they are the result of repeated and grave injustice against black mothers, black futures, and black families. Are we going to keep being comfortable with this atrocity?
“These statistics are not just an unfortunate thing that is happening to people; they are the result of repeated and grave injustice against black mothers, black futures, and black families.”
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Every story I read of traumatising birth experiences, and in severe cases, death, echoes a sentiment that is known all too well by black women: covert dismissiveness, blatant accounts of stereotyping, and a sense of invisibility to others. Behaviours like these have names that, unless spoken of, are perpetuated by ignorance: microaggressions and systemic and cultural racism. Microaggression is “a term used for commonplace daily verbal, behavioural, or environmental slights, whether intentional or unintentional, that communicate hostile, derogatory, or negative attitudes toward stigmatised or culturally marginalised groups.”
Microaggressions often manifest as backhanded compliments and subtle insults. For instance, black women are often referred to as ‘strong’. Whilst this can be regarded as a compliment to some extent, it is frequently used in a way that denies expression of pain or concern. FixeXMore is a grassroots organisation committed to positively changing the birthing experiences of black women and birthing people in the United Kingdom. Annabelle’s story is one featured on FiveXMore’s blog, and illustrates the harm that these types of microaggression cause. After having a Caesarean section, Annabelle expressed concern about how well her scar was healing, to which midwives responded that it was “fine”, and they were “amazed by how well it had healed”. She discovered that her scar was in fact infected after taking herself to hospital. Whilst these midwives may have had very little experience with black skin, as Annabelle acknowledges in her blog post, their dismissal of her concern and appraisal of her skin highlights the unconscious racial bias they may have been displaying. Other stories on the FiveXMore’s blog detail the ways in which microaggressions undermine the care and the needs of the people in question. These aggressions often leave individuals traumatised and tired; tired of advocating endlessly for things that should be a basic right. There is a perception that microaggressions are just people being too sensitive, but I believe these microaggressions matter and that they are a big deal.
“Cultural differences and racial biases act as barriers for black people to access health care and to be seen, heard, and understood by healthcare professionals.”
Accounts like these are not limited to black women’s birthing experiences. Microaggressions are seen in differential treatment of members of the black community in the workplace and healthcare settings. Cultural differences and racial biases act as barriers for black people to access health care and to be seen, heard, and understood by healthcare professionals. These biases explain why black people are four times more likely to be detained under the Mental Health Act, but less likely to receive support and adequate treatment. Sickle cell disorders, which affect approximately 15,000 people in the UK, are predominant in black African, African Caribbean, Mediterranean, and populations of Asian origin. Despite their prevalence, these disorders receive 30 times less funding than cystic fibrosis—a disease which affects around 10,000 people in the UK. The racial disparities in medical research can be attributed to systemic racism which, contingently, negatively impacts the quality of care sickle patients receive. Several factors contribute to the disparities listed above. However, figures repeatedly show that systemic racism is at the centre of the issue. Avoidance of the subject, lack of action, and persistent failure to acknowledge the ways in which people who benefit from the system do so at the expense of others, are all reasons why being a sick black person or pregnant black woman is a dangerous state to be in.
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Unfortunately, this is not a problem that is unique to the UK. In the United States, black women are three times more likely to die from pregnancy and childbirth related complications. Cystic fibrosis affects less Americans than sickle cell disease but receives seven to eleven times more research funding per patient—findings which mirror those in the UK.
It breaks my heart to say that there is an insufficient amount of research on this topic and that there are no policies in the UK that protect and support black mothers. Maternal care is available locally for women across the UK, and there are mainstream initiatives, such as Better Births, which seek to improve birthing experiences and support women. However, there are few initiatives tailored to black women. In the wake of the COVID-19 pandemic, the Care Quality Commission conducted an analysis which resulted in the launch of a programme that aimed to reduce the risk of Black, Asian, and Minority Ethnic (BAME) mothers contracting COVID-19 and suffering further adverse health complications. A continuity of care plan, which is targeted at women from BAME groups and women living in deprived areas, has also been set up by the National Health Service (NHS) as part of their long-term plan in effort to improve quality of care and reduce preterm births and perinatal mortality. Additionally, a petition launched by FiveXMore’s co-founders, Tinuke Awe and Clotilde Rebecca Abe, has invoked a series of governmental action points. The proposed government action and programmes are steps in the right direction, but must be taken forward to provide support black mothers.
I do hope for one thing in the fight for better maternity care for black women: a culture shift. Systemic and cultural racism has been highlighted as the overarching contributor to multiple racial disparities in healthcare and in wider society. Laws, processes, and cultural norms in the UK that benefit white people have damaging implications for members of the BAME community. I personally believe that new policies and programmes will not address the full picture unless they embody an active effort to dismantle and remove the conscious and unconscious biases that have given room for issues like this to exist. We must address the risk factors and contributing factors that lead to the death of black mothers, and we must make every effort to fund research to improve this. But it is imperative that we look at ourselves first. We cannot continue to make presumptions that black women and black people are more likely to be front line workers and come from overcrowded households without acknowledging that societal constructs have routinely placed BAME members at a disadvantage. We cannot conclude that black women are more likely to suffer from pregnancy related complications, and assume that this is enough to explain these statistics. We must think why, and consider why we have not thought about the why before. We must try to understand black women, let them be seen and heard, and admit when we don’t understand so their care can be better informed and refined. It is not enough to put policies in place when they have often marginalised black people; cultural reform is needed.
“For the sake of black babies, the black futures that blossom as these children grow, the black women and futures that we have lost at the hands of this: we must protect black women.”
The generation of women after me must not cry the same cry of injustice. The generation of women after me should not have to endure the fear of being invisible, misunderstood, and ignored. They should never have to subject the trauma of a preventable negative birthing experience. These figures will continue to add to the racial biases that black women face if we do nothing. For the sake of black babies, the black futures that blossom as these children grow, the black women and futures that we have lost at the hands of this: we must protect black women. We must design systems that support and benefit them, and, as a society, we must uproot all barriers opposing this. This epidemic has to end with our generation. We need to treat the current status of black maternal mortality like the crisis it is—childbirth should never be this dangerous.
The author recognises that not all black birthing people identify as women and mothers. Along with Oluwaseun’s reflections as a black cis woman, more research and voices are needed on the experiences and injustices of black trans people and folks across the gender binary, too.
The following websites offer resources to support black mothers and mothers-to-be, and BAME members with their mental health:
Black Mums Matter Too: A community for black mums and mums to be.
Black Minds Matter: Free mental health services for black individuals by black professional therapists.
Therapy for black girls: Wellness, resources, and therapists for black women.
Artist spotlight: David
Gwen features the works and journey of artist, photographer, and entrepreneur, David. David advocates for physical and mental wellbeing to support the health of communities.
Content warning: this article contains mentions of racism and mental illness.
Back in 2019, David Lee turned his camera towards me. I felt self-conscious and suddenly didn’t know how to be natural in my own skin. But his approach to photography centred on connection and introspection, which made the experience more like a cathartic release than a purely aesthetic pursuit. He gave me the opportunity to talk about the things that were on my mind and reminded me how to be myself again. David and I met as community advocates who were still exploring the ways that we fit into supporting the social, environmental, economic, and health needs of our microcosm of community. Most of our conversations were about how we work in relationship to the community and how we take care of ourselves. That night in my flat we had the same conversation but somehow it felt more vulnerable to have a camera there and to have it be documented: at the same time, it was therapeutic to have those moments preserved. David has taken that intimacy of documentation and turned it into his full-time pursuit as a photographer and artist.
Photography by David Lee
Creativity has always had a place in David’s life, but his emergence as a creative was tangled with his identity and wrangling with others’ perceptions of him. He recalls that different learning environments impacted the reception of his art by his teachers. Early on he was not encouraged to pursue art, which raised larger questions on how stereotyped identities, specifically expectations of black people, can hinder and limit growth. “I think sometimes black people are expected to perform in certain ways … looking back I didn’t get the encouragement like my peers did, and I won’t say why, but I noticed that, and it got to me.”
Photography by David Lee
Initially, this kept David from identifying as a creative. It wasn’t until middle school that his poetry was recognised and won a competition. “I remember winning that and the first time feeling like I was a creative. Like my school actually did think it was a big deal. The school was majority black and that was the first time I went to a predominantly black school.” This recognition and ability to self-identify as someone who is creative gave David license to continue exploring his art, which soon led him to photography.
His exploration of photography began as an ode to memories and an outlet for his own depression. Looking through old family photos in what his family called their “library”, David became interested in photos and memory. “These memories are important. I realised how important they were to me. So, I went and bought a bunch of disposable cameras and went around taking pictures of middle school.” Reflecting back on this period of time, David recounts some of his own struggles with depression and finding photography and poetry as a means of dealing with his own internal world.
“I can see that’s when my childhood depression started to manifest the most and so I needed these outlets. Friendships were starting to look weird … my art usually centres around mental health and trying to create these outlets of expression so people can process and see themselves reflected back. I think that’s when it started for me.”
Photography by David Lee
Memories of middle school years are ones he has shared with me a couple times, and it brings together so many aspects of David that I’ve come to know. He has an incredible ability to capture vulnerable, authentic moments. Part of his art is tapping into the undercurrent of a moment and pulling out the right words and images that describe some of those unspoken emotions. Photography is his way of slowing things down in an age of hyper-stimulation. “It’s a chance to press pause and allow people to go back to that moment and think about what they were feeling and see the subtleties of who they are”. Oftentimes, David shares his photos with poems and prose about that moment, the interaction, or what the experience brought him. Whenever I see David’s work, photography and poetry paired together, there is no doubt it’s his voice and vision that come through.
Photography by David Lee
“Photography is his way of slowing things down in an age of hyper-stimulation. “It’s a chance to press pause and allow people to go back to that moment and think about what they were feeling and see the subtleties of who they are.””
During the summer of 2020, George Floyd was murdered. Black Lives Matter protests spread across the United States and around the world. David was there—documenting through his lens the rawness of the people, the protests, the events, and the emotions.
The pandemic was ongoing in the backdrop, which brought into sharp focus health inequities, particularly in black communities. The broader social conversation around racism, critiques of the carceral system, and health inequities shifted—it was suddenly more critical, urgent, and mainstream. “During those protests I realised this wasn’t my space anymore. I started to see allies showing up and screaming at the top of their lungs, with signs and linking arms on the frontlines. Like ‘Huh, cool it’s been done’ and it felt like the energy shifted. So where do I need to go if this isn’t the space, because the work needs to continue. I chose physical health, community, and mental health. Getting outdoors was the way to do it.” The protests in 2020 felt different to him and having allies show up in those spaces offered David the flexibility to do the work he really wanted to do. This was when he transitioned to being a full-time co-founder and photographer.
Photography by David Lee
Choosing the name of his organisation was an act of radical self-naming and claiming an identity. David reflects: “How is that going to come off to people, is that marketable? But in my community it’s important to say this is who we are and not allow other people to dictate what our expression should be. … So, I started the organisation Negus in Nature (NIN) with my business partner Langston”.
Within NIN, David is in his element—sharing the joys of the back country while documenting a community becoming connected with their mental and physical wellbeing outdoors. He’ll be starting his artist residency at the Kala Institute, which will give him access to an array of mixed media materials. He’s really excited to be sharing some of his new works coming up as he says, “A lot of the protest photos I have not shared yet because it’s like ‘aight this is raw and I don’t know what this is for just yet … and so now everything is coming together and it’s this collective idea of ‘this is where I was in the pandemic and this is where I was before and this is the processing.’” He wouldn’t share much more about his upcoming project, but he’s dreaming up something with paper mâché, dabbling into the world of mixed media.
Stay up to date with David’s projects on Instagram: @d.xoti
You can follow NIN’s adventures on Instagram: @negusinnature
If you want to sign up for an excursion you can visit NIN’s website