Editorial: Racism and discrimination in mental health services: What is the question?

Introduction

The question of race and racism has been well-recognised as influencing presentation of psychiatric disorders and help-seeking as well as pathways to care and also acceptance of therapeutic measures. These observations have been reported from many countries around the globe. There are both similarities and differences in this endeavour as cultures and healthcare systems differ widely. However, there remain major challenges in our understanding of what these terms mean and how they are employed. The ascription of race and racism can be misused for a number of reasons. Problems with accessing services may be to do with perceived institutional racism. Often those who experience it directly or indirectly see these experiences in very different ways than those who are seen as creating these emotions and responses.

Racism

The theory of racism was developed in 18th and 19th century Europe by the theory of races which defined a natural division of humankind into subspecies placed in a hierarchy (Birdman 2002). Theory of races became a major tool in the development of racism as it allowed discrimination and segregation to prosper and become institutionalised. Religious conflicts over the centuries may well have contributed to this creation of division, otherness and potential conflict. Thereafter, Bethencourt (2013) observes that historical use of the noun race led to creation of racism. He notes that Febvre (1962) pointed out that content may exist before the noun that expresses it. Snowden (1983) using historical context identified that prejudice against barbarians by the Greeks was cultural rather than natural thus confirming that prejudices are probably modifiable as and when cultural factors change and evolve. However, Isaac (2006) contests this view and argues that prejudices were produced steadily and spread widely and were indeed detrimental to their victims. He added that these prejudices produced certain challenges to status as well as identity. Bethencourt points out that such an approach makes the case for rooted prejudices concerning collective descent but no consistent and systematic discriminatory action. It would thus appear that prejudices have existed for millennia.

Fredrickson (2008) notes that informal racism had existed for a long time, and institutional racism backed by the state in various institutions that the state was responsible for emerged subsequently. This type of racism is often about keeping hold of perceived and real privileges which are to do with financial and status privileges. Institutional racism is about creating the other where privilege and power is held on the basis of perceived differences often attributed to race. This otherness and otherism thus has a role which allows prejudice to flourish. Racism and religious discrimination can be seen as interconnected as different religious affiliations were often seen as inferior to certain religions. Bethencourt points out that separation between religious and natural hierarchies is much more blurred (p. 4). He goes on to argue that racism occurs around the world as a part of the human condition. Thus, it has a role to play in confirming the identity of individuals and creating otherness which validates identity. On the other hand, Marxist perceptions and integration of racism in daily functioning is related to means and output of production and associated with ethnic descent and discriminatory action as an ideological and political mainstay of the accumulation of capital. By keeping wages low and justifying the exploitation of humans seen as inferior (Balibar and Wallerstein 1991) and thus creates a working class, this provides justification for discriminated against the group. Bethencourt (p. 3) points out that this follows on from Aristotle’s concept of natural slavery which justifies and creates a framework for bonded labour. This observation highlights that racism and discrimination are not blunt but subtle nuanced actions.

Political and social aspects of racism are related to monopolisation of power (Weber 1978). The monopoly of social power and prejudice create discrimination which then creates social disadvantages to people who are the other and in the course of time, it becomes institutionalised. It is therefore likely that following this, political and social systems change and adapt to this malfunctioning concept.

Bethencourt (p. 6) reminds us that the nouns ‘racist’ and ‘racism’ were created as recently as the 1890s and 1900s to designate those proclaiming racial theory along with hierarchy of races. Political factors created a sense of hostility among racial groups. It is worth reminding ourselves, as Bethencourt (p. 6) does, that while the noun racism has acquired a precise content the meaning of the noun race is extremely unstable. This degree of disparity thus raises key questions about the over expansion of both the terms thereby ignoring subtlety and nuances in definition and usage be it colloquial or academic. Race has been used synonymously with caste and with lineage coupling the two. The historical development and subsequent application of these terms has been described by Bethencourt.

Racism is about otherness and targets not only ethnic or religious group seen and deemed as inferior but also groups who are seen as competition. Racism is to be differentiated from ethnocentrism as the former targets groups with which the reference community is engaged, whereas the latter may express contempt towards another community but is able to include individuals from that community.

One of the early volumes which looked at racism and mental health by Willie et al. (1973) described the situation in the United States of America (USA). It is worth recognising and emphasising that even though there may be some similarities across cultures and countries, often there are clear differences too which must be taken into account. Prudhomme and Musto (1973) while providing a historical account from a USA perspective propose that racism has been related to racial theories of mental illness particularly as mental illnesses were seen to be related as due to environmental and constitutional factors. In early epidemiological studies, low rates of mental illnesses in Black populations were seen as due to their uncivilised nature or comforts of slavery. Differential rates of various psychiatric disorders were reported. Until relatively recently there was a presupposition that Africans had low rates of depression because they were not civilised enough. It is worth emphasising that rates of different psychiatric disorders in minority groups who may be vulnerable are a combination of psychological, social and biological factors as various papers in this issue demonstrate. The paper on otherism and otherness by Bhugra et al. provides a broad overview. These authors use the concept of identity to describe otherness which can lead to otherism. It is important to note that identity is a complex concept moulded by cultural, biological, psychological, experiential, and social influences including religion. Various types of identities include social, personal, familial, cultural, political, religious, gender and class identities. These multiple and complex micro-identities mould unique and diverse interactions at an individual level. These may be expressed selectively and aspects may remain hidden coming out only at times of aggression.

This themed issue provides an overview of racism and discrimination related to mental health in general principles but also reviews and research across different ethnic and cultural groups. There are different types of racism such as Dominative (where hatred turns into actions); Colour-blind (where acceptance of differences is seen as culturally divisive and everyone is seen as the same); Missionary (which means that one individual is convinced that they know what is good for the other person and perception that the other individual cannot think for self; other types may include behaviours and actions depending upon negative and discriminatory attitudes towards the other. These attitudes then are very likely to turn into negative and discriminatory behaviours which may reflect underlying fear, suspicion or frustration with the other. However, it is the creation of the other which is at the core of these negative behaviours and attitudes. Identity and its various aspects thus become the heart of creation of the other.

Bhugra et al. (in this issue) note that social identity is recurrently defined in opposition to perceptions of the other. This perception can give ideas of superiority and privilege which can contribute to creation of further marginalisation of the other be they due to religion, psychiatric disorders, sexual orientation etc. These characteristics can lead to stigma and discrimination. Sociological contexts have developed this theory of otherness but in clinical psychiatric contexts, this is significant because it contributes to risk and causative factors and creating mental health inequalities. Such a construction of otherness and its detrimental outcomes for psychiatry are critical in our learning as these lead to systemic discrimination and disparities in therapeutic interventions. Policy impact on effects of otherness thus needs to go beyond specific issues such as racism, homophobia, misogyny etc as all these consequences go beyond a single issue. Awareness of the other must form part of cultural competency training, interventions informed by micro-identities and intersectionality, patient advocacy, and structural changes to mental health policy.

Ventriglio and colleagues (in this issue) in their narrative review, point out that there are a range of variables related to racism, such as cultural, institutional, interpersonal factors. These in combination with the concepts of perceived and internalised racism are relevant characteristics of institutions which may affect racism and consequently its impact on mental health not only of the patient but also on carers and families. They illustrate some of these issues from the epidemiological data on the prevalence rates of depressive symptoms, psychotic symptoms and substance abuse/misuse among minority populations who face discrimination. As they argue, anti-racism policies are essential in order to address racism and racial discrimination. However, it is critical that majority populations are not only involved in any such decisions but also have an ownership so that they do not feel alienated and discriminated against. Understanding the impact of race and racism on mental health and wellbeing across different parts of the society is important. Another major issue that policymakers need to be aware of is the difference between equity and equality. Equality means that everyone gets the same thing whereas equity refers to targeted interventions according to need.

Kastrup (in this volume) as well as Torales et al. (in this volume) make similar points in that the impact of racism and consequent discrimination can be pervasive and affect mental health of individuals, therefore, policymakers need to be cognisant of differential needs. Kastrup points out the ubiquitous nature of racism and notes that it can manifest in several, often-overlapping forms such as personal, internalised or institutional. Personally mediated racism refers to deliberate social attitudes and behaviours and actions which lead to discrimination towards others according to their race. The other individual is thus devalued and stereotyped on the basis of certain characteristics and these negative responses then go on to contribute not only to mental and physical ill-health but also delays in help-seeking. Managing racism requires interventions at multiple levels from individual education and training, institutional responses and policy measures at national levels which can be achieved only with adequate and proper funding. Torales et al. (in this volume) make a similar point in that stigma and discrimination influence patient outcomes because their access to and acceptability of therapeutic interventions is affected. These behaviours on part of larger majority will affect their quality of life, general wellbeing, social inclusion and employment opportunities. They argue that social stereotypes and prejudice will contribute to continuing discrimination in mental health. A lack of knowledge and understanding of mental health/illness by individuals, their families, carers and policymakers as well as the role social media plays impact on social attitudes to discrimination. In addition, many other groups are vulnerable due to specific characteristics.

Schouler-Ocak and Moran in their paper (in this volume) remind us that there is a link between discrimination and racism which go on to affect physical changes in the brain volume which can in turn lead to behavioural changes. These interconnections need to be understood so that policy changes can facilitate and act as preventive measures. Mylord et al. (in this volume) make a similar point and in their observational study note that a potential buffering factor in dealing with discrimination is psychological resilience. They identify such resilience as encompassing the ability to recover from or adapt successfully to adversity using coping strategies, such as positive reappraisal of adverse events. They report on the role of resilience as well as social support in buffering these effects from data in groups of migrants to Germany both with and without local residence permits. The two groups were compared on the social support, resilience, discrimination and general mental health. Not surprisingly those who did not have residence permits were more likely to report perceived discrimination. They also had lower levels of social support which may thus act as a mediator. The authors conclude that, not surprisingly, citizenry status is important for better psychological adjustment. Similarly, a different identity characteristic has been noted. In a meta-analysis Lazaridou et al. (in this volume) found that there was a strong direct overall association between racism and mental health which was strongest for externalising and internalising symptoms. Interestingly, they observe from their data that racialised identity had a moderating effect on the associations between racism and internalising as well as externalising symptoms. It is possible that minorities with a low racialised identity may be more susceptible to experiencing negative mental health outcomes in response to racism.

Trislenik et al. (in this volume) take the view that process of migration, consequent displacement and travel to new country are major challenges to mental health. They report from a population-based cross-national comparison study which explored symptoms of depression, anxiety and somatisation as well as quality of life in three samples of ex-Soviet Jewish migrants settling in Germany, Austria and Israel. These groups were compared with a sample of non-migrant ex-Soviet Jews in their country of origin, Russia. These researchers studied the relationship of perceived xenophobia and antisemitism, acculturation attitudes, and ethnic and national identity. In addition, degree of affiliation with their religion and culture were studied. It is well recognised that religious adherence can be an important part of resilience and to psychological well-being. These aspects were looked at. These authors report that attitudes of the new country’s society matter for the mental health of this migrant group. Not surprisingly the levels of distress among ex-Soviet Jewish migrants seems to depend upon the attitudes and reception in the new country as well as interactions with the population of the new country.

Covid-19 pandemic has introduced another level of racism where minority groups, particularly from South East Asia, were seen as being responsible for the global spread of the virus and consequently targeted. Soon after the pandemic started, many Chinese restaurants and take-aways were attacked in the UK and elsewhere. This blaming the other, along with the spread of opinions through the social media, creates a new scenario that needs looking at carefully. Keum and Choi and Keum and Wong (papers in this issue) have done precisely that. In the first study by Keum and Choi, the authors set out to explore the heterogeneity of online racism experienced by Asian, Black, and Latinx adults in the USA and found that high exposure to racism was reported by the Asian and Black groups. In addition, a more sustained exposure was unique to Asian and Latinx groups indicating greatest resulting psychological distress and unjust views of society compared to all other classes. There were gender differences too. Their conclusions that exposure to online racism is multi-dimensional is an important message thereby confirming that racism has multiple tones and dimensions, hence it is important to recognise divergently risky subgroups. It is likely that chronicity of these experiences as well as class status of the victims may well change over time thereby altering additional antecedents online as well as health consequences.

In a further study, Keum and Wong studied anti-Asian racism and suicidal ideation among young Asian American adults and the relationship with increased thwarted belongingness and perceived burdensomeness. Not surprisingly they found that COVID-19-related anti-Asian racism significantly predicted suicidal ideation among these groups. It can be argued that such attacks affect self-image and perceived and real discrimination further add to this sense of hopelessness. Keum and Wong found that indirect effect through perceived burdensomeness was significant which was higher as a result of COVID-19 related anti-Asian racism and thus was associated with greater suicidal ideation. It is not surprising that their findings highlight that the ongoing COVID-19 anti-Asian racism may be an alarming risk factor for suicidal ideation for Asian American young adults. Online racism is a digital social determinant to health inequity, and an acute and widespread public health problem.

It is well described that minority groups are more vulnerable to attacks related to race and otherness. In this volume, three groups – indigenous Maori people from New Zealand, transgender people from Russia and asylum seekers from Germany – are described. In their study from New Zealand, Manuel et al. (in this volume) used a qualitative method to study evidence of Indigenous and ethnic minority inequities in the incidence and outcomes of early psychosis. They looked at how racism is defined and how racism operates as a socio-cultural phenomenon that interacts with institutional policy and culture across systems. All these factors influence social responsiveness, risk discourse, and consequently structures of mental health services. They studied selective responses based on racial stereotypes along with race related risk assessment bias, as well as institutional racism in the mental health workforce. Racism led to an inaction in the face of social need, increased use of coercive practices, and an under resourced Indigenous mental health workforce. These findings are not dissimilar to what is seen across other healthcare systems such as in the UK. Their observations illustrate the inter-related nature of interpersonal, institutional, and structural racism as noted by Ventriglio et al. as well as Kastrup in this volume. Interpersonal racism in the form of negative stereotypes interacting with organisational, socio-cultural and political priorities is likely to affect mental health and wellbeing. Thus, institutional and organisational cultures may differentially impact Indigenous and minority people in a number of ways. All of these need to be targeted for anti-racism efforts.

Looking at otherness, from Russia, Chumakov et al. (in this volume) report on the stressors and perceived need for mental health care among transgender people. Not surprisingly, there are multiple stressors faced by minority groups. An overwhelming majority of respondents reported stress in their lives including financial problems, relationships with relatives as well as intimate relationships. Not surprisingly, consequent psychological distress interfered with their ability to lead a fulfilling social life. Virtually half of them reported problems related to seeking mental healthcare attributable to discrimination and stigma. It was no surprise that over one third of their sample reported taking non-prescription or off-label medications to improve their well-being or mood. Studying the third vulnerable group of asylum seekers and refugees, Graef-Calliess et al. (in this volume) present findings from a large sample of asylum seekers in Germany. They studied the relationship between post-migration stressors and mental health in treatment-seeking asylum seekers and refugees. Participants got significantly better after treatment but post-migration living difficulties and perceived discrimination significantly predicted all mental health outcomes. Interestingly, they found that perceived discrimination contributed significantly to the prediction of quality of life and traumatisation. Thus, appropriate therapeutic interactions play a major role in improving mental health.

Although the present issue of the journal looks at racism and discrimination, the focus must remain on how and why we create the other, and the reactions to such a creation which then perhaps are validated by feelings of superiority and privilege whether that is due to gender, sexual orientation, religion or any other micro-identity. The creation of the other is not a recent phenomenon but often the focus has been on one or more characteristics which appear to overwhelm others. As mental health is strongly influenced by cultural, social, environmental factors as well as epi-genetic processes which create biological changes, it is crucial that clinicians look at these factors both broadly and also in a focussed manner and societal reactions to these as well. Policymakers need to take an overview on othering. Although it can be argued that focussing on a single reaction makes it easily manageable in terms of getting rid of discrimination, the tragedy is that single reactions can be easily overlooked. By blaming a single condition such as racism as a cause of all the problems takes away responsibilities for consequences of otherness which may produce misogyny, homophobia, transphobia, Islamophobia and anti-Semitism among other consequences as well as causes leading to these attitudes. Economic, educational and social class all play a role in how we see others and how we see them seeing us.