Reprinted with permission from Openmind 98 (July/August 1999) © 1999 Mind (National Association for Mental Health)

POST-PSYCHIATRY

Pat Bracken and Phil Thomas

The Macpherson report into the racist murder of black teenager Stephen Lawrence has echoes in every corner of our lives. As the report says, “It is incumbent upon every institution to examine their policies and the outcomes of their policies and practices to guard against disadvantaging any section of our communities.”1. This is particularly so in the Health Service and psychiatry, but the report challenges us to reject the limited notions of anti-racism which remain popular in many institutions, including the NHS. In the past, anti-racism has been regarded as consisting of little more than injunctions against discrimination and giving offence. Macpherson, however, speaks of institutional racism in terms of a failure to reach out and engage with ethnic minority communities in a proactive way. It involves a failure to listen to what communities say about their experiences in this country, and a failure to address the issues of difference in a positive way. McKenzie’s 3 recent editorial in the British Medical Journal argues that institutional racism goes to the very core of health care practice, and that in the area of health we can identify several consequences of institutional racism. People from ethnic communities have poorer health, poorer access to services, and are treated differently, especially in psychiatry. Doctors from ethnic minorities experience discrimination in selection for medical school, and shortlisting for jobs. According to McKenzie, institutional racism is an ideological problem. Although inequalities in health are brought about by social, economic and political factors over which the medical profession has little influence, the dominant ideology of the medical profession, the importance it attaches to an individual biomedical model, means that the consequences of inequality are systematically played down. Nowhere can we see this more clearly than in psychiatry, and in particular in the way in which the biomedical model has been set to work in the Defeat Depression campaign.

This campaign, which has now ended, was set up as a joint initiative by the Royal College of Psychiatrists and the Royal College of General Practitioners, in response to a concern that many people in the community were suffering from depression which went unrecognised, and untreated. Its purpose was to improve General Practitioners’ skills in identifying and treating depression. But this hides a number of assumptions that require careful consideration. For example, it assumes that ‘depression’ as defined by the biomedical model is the correct way of interpreting human emotional distress. It also assumes that such distress has no intrinsic value and must be got rid of through the use of antidepressants, or other technical interventions, such as therapy. It is important to remember that this view has developed over the last 250 years within Western culture. In this tradition, human distress is understood in terms of inner disturbances that are located within the individual’s mind or brain, and the technologies of psychiatry and psychology are regarded as legitimate ways of rectifying these disturbances. In some of our earlier articles we have pointed out that such interpretations are by no means universally accepted within our own culture, but the assumptions implicit within the biomedical model become even more problematic when they are imposed on people from non-Western cultures, who may not share Western concepts of mind and brain, or the values that are attached to Western concepts of health. In effect, Defeat Depression means that the patient’s interpretation of his or her experiences must fall into place with the doctor’s narratives about depression, which of course is located within the biomedical model. The campaign privileges the biomedical model with the result that other, culturally appropriate ways of interpreting distress are marginalised. There is more than an element of colonial arrogance in this position, and an insensitivity to other narratives of suffering. It also trivialises the importance of social and environmental factors in understanding the meaning of suffering. It implies that factors such as unemployment, bad housing, racial harassment, and poverty are of little value in helping us understand the origins of human distress.

Institutional racism occurs in many guises, but the imposition of a dominant culture’s beliefs and values over those of people from minority groups constitutes one of its most powerful variants. In our view, Defeat Depression means that a culturally inappropriate way of interpreting human experience may be imposed on people from non-Western cultures. It must be emphasised that this is not done intentionally, so as to place non-Western people at a disadvantage. But it arises from a lack of understanding of the complexity of culture, and out of ignorance that the biomedical model is itself a product of culture, and is saturated with Western values about the nature of health and illness. This in our view constitutes institutional racism in clinical practice. It highlights the weakness of clinical practice which is not informed by what McKenzie calls the ‘perceptions, needs, and aspirations of ethnic minority groups’. Perhaps psychiatry would be better off curbing its colonial ambitions, and for once turn to listen to those voices which so often remain silent in its presence. The title of our column is ‘Post-Psychiatry’. By using this term we are looking to a situation where there is a new relationship between medicine and the experience of madness and distress, a relationship which is not mediated a psychiatry centred on an individual biomedical model of illness and healing.

References

1 Macpherson W. The Stephen Lawrence inquiry. Report of an inquiry by Sir William Macpherson of Cluny. London: Stationary Office, 1999.

2 Department of Health Press Release, Tough action announced to tackle racism in the NHS. Thursday 11th March, 1999.

3 McKenzie, K. Something borrowed from the blues? British Medical Journal 318:616-617, 6 March 1999