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Transcultural mental health care and the challenge to positivist

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Transcultural mental health care and the challenge to positivist

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    David Ingleby

    Utrecht University, The Netherlands Transcultural mental health care: the challenge to positivist psychiatry

In this chapter, I will try and explain why I think there is an important overlap between

    „critical psychiatry‟ and the movement to provide better mental health care for migrants and

    ethnic minorities, which I have been involved in since the beginning of the 1990‟s. My

    interest in this movement was partly motivated by personal experience: I had myself relocated

    from Britain to The Netherlands in 1982 and had learned at first hand how complex the

    processes can be which accompany migration. But in more „objective‟ terms, it was also

    dawning on me that ethnicity, cultural diversity and globalisation were becoming the burning

    issues of our time.

    In The Netherlands, a movement devoted to improving mental health service provision

    for migrants and ethnic minorities had existed since the end of the 1970‟s. This movement

    consisted of a network of highly dedicated individuals, many of whom were themselves

    migrants. A lot of the issues they discussed were very familiar to me from my involvement in

    the critical movement in psychiatry and psychology. This was despite the fact that issues of

    race and culture had, in fact, received very little attention during the 1960‟s and 1970‟s. The critical movement‟s preoccupations were largely confined to white, Western society: gender

    and class differences, for example, were high on the agenda, but topics such as the link

    between colonialism and psychiatry, or the Western bias of psychological knowledge, did not

    come to the fore until later (e.g. Fernando, 1991).

    Nevertheless, the movement for transcultural mental health care showed a strong overlap

    with the earlier critical movement three important respects.

    1. There was a similar emphasis on the social context of psychiatric problems. People

    rejected the notion that psychiatric problems were purely located inside people‟s heads

    and looked for the situations which could make the so-called „symptoms‟ intelligible.

    2. The question of power relations was central to both movements both the power

    relations between professionals and clients, and the way in which mental health care

    could help or hinder the „empowerment‟ of marginalised groups in society.

    3. Lastly, both movements argued for new paradigms: not simply for adding a new topic

    to the mainstream agenda, but for fundamentally rethinking theories, research methods

    and approaches to treatment.

In what follows, I will explore each of these themes in turn.

    1 To appear in D.B. Double (ed.), Critical Psychiatry: The limits of madness [in press]

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Critical psychiatry

    First, however, I should say a bit more about what I take „critical psychiatry‟ to be. Although

    the collection I edited in 1980 under that title was I think the first book to use the term, I

    would make no claim to having invented it myself or to having provided an authoritative

    definition of it. For me, critical psychiatry is at best a „fuzzy set‟ – a loose coalition of

    thinkers and actors whose ideas display certain family resemblances, but who are not united

    by a common credo or agenda. Perhaps the best way to explain what it means to me is in

    autobiographical terms: how I myself experienced it.

    As a psychology student at Cambridge at the beginning of the 1960‟s, „clinical‟ topics

    fascinated me the most, but after graduating I rejected the option of joining this profession.

    Clinical psychology seemed to me a rather closed world, dominated by a few conflicting

    dogmas such as behaviour therapy, family therapy and psychoanalysis. My first experience

    with psychiatry in practice had been vacation work as a Nursing Assistant in a „therapeutic community‟ at Littlemore Hospital, Oxford. This was an intense and gripping experience.

    At the time, the ideas of Maxwell Jones were being put into practice at Littlemore by a

    daring and original colleague of his named Ben Pomryn. The hospital formed a striking

    portrait of contemporary psychiatry, being architecturally divided into two wings known as

    the „A side‟ and the „B side‟. The A side was a monument to classical, Kraepelinian

    psychiatry: heavily sedated patients shuffled along the endless corridors or lay motionless on

    their beds, under the watchful eyes of a hierarchy of uniformed professionals. By contrast, the

    B side was teeming with activity and emotion: group meetings several times a day encouraged

    patients and staff alike there were no uniforms to mark the difference to “let it all hang

    out”. The ensuing shouts, screams and laughter wafted across to the classical psychiatrists on

    the A side, who shook their heads in disbelief and concluded that their colleagues had gone

    completely and utterly mad.

    On the B side we regarded ourselves as the ultimate in progressive psychiatry, but we

    were amazed to learn that other schools of thought existed which regarded our work as

    positively reactionary. At Littlemore, the ultimate gesture of defiance against the established

    order was made by two long-term inmates who one day horror of horrors! copulated in

    full daylight on the cricket pitch. Not long afterwards, however, we received a visit from an inmate of David Cooper‟s „Villa 21‟, who informed us that this act had not been revolutionary

    at all. Only copulation between a staff member and a patient could aspire to that status.

    Treating schizophrenics in newfangled ways was not revolutionary, either: the task was to

    abolish the concept of schizophrenia itself. My curiosity was aroused and I went on to read

    the writings of Cooper, Laing and the other „anti-psychiatrists‟. Later, I moved to London and made first-hand acquaintance with the anti-psychiatry movement. I realised that, leaving aside

    the questionable issue of sex between staff and patients, there was a whole new discourse

    about mental disorders in the making, in terms of which the A side and the B side at

    Littlemore were actually not as different from each other as I had imagined.

    Even now, I find it hard to categorise the „anti-psychiatry‟ movement or to define what it basically stood for. Some of its members had overtly political ambitions; others preached

    individual self-realisation; others still had their sights set on harmony with the cosmos. Some

    valued the helping professions and sought to develop their therapeutic skills; others dismissed

    the concept of therapy as absurd. Some were erudite, others totally unschooled; there were

    refugees philosophers, writers and artists who had fled from communist Eastern Europe or the United States Military Draft.

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    Around the crucial year 1968, the whole of academia became caught up in a wave of critical fervour and was engaged in vehement discussions about its presuppositions and its

    role in society. The central theme of the critics was that society is not a harmonious whole,

    but a power struggle, and the important question everybody had to ask themselves was

    “whose side am I on?” If you weren‟t part of the solution, you were part of the problem.

    In the second half of the 1970‟s, a lectureship at Cambridge University helped me considerably in deepening my understanding of the historical and political issues surrounding

    mental health care. Figures such as Roy Porter and Bob Young were working out a critical

    approach to the history of medicine and biology, and the students I taught, both in Social and

    Political Sciences and in Medicine, were enthusiastic and receptive. I eagerly accepted a

    proposal from Penguin Books for an edited volume on the topic of mental health, and in 1980

     after a long delay, due to a combination of my own inefficiency and the publisher‟s –

    Critical Psychiatry saw the light of day. The title was anything but original; the 1970‟s saw

    the rise of critical anthropology, critical biology and even, for all I know, critical tree surgery.

    However, by 1980 the critical movement in Britain had pretty much ground to a halt. Mrs.

    Thatcher was at the helm, Ronald Reagan was poised to take over in the U.S.A., the economic

    recession was deepening and 1968 was beginning to feel like a very long time ago. It came as

    no surprise that the book‟s sales remained low. Looking back, however, it seems to me that

    the book managed to present many of the themes that characterised the critical movement in

    mental health.

    What exactly was this movement? Firstly, although Laing and Cooper managed to capture the role of standard-bearers for the critical movement, it was actually much broader

    and deeper than the „anti-psychiatric‟ views which they propagated. In 1997 I had the good

    fortune to attend a conference on the post-war history of psychiatry in Britain and The

    Netherlands, organised by Marijke Gijswijt-Hofstra and the flamboyant, brilliant and now

    sadly missed Roy Porter (see Gijswijt-Hofstra & Porter, 1998). The research studies presented

    at that meeting confirmed my impression that anti-psychiatry had seized a disproportionate

    amount of attention and that the critical movement was not only much broader, but also to a

    considerable extent a part of psychiatry itself. For example, much of the resistance to biological

    reductionism in psychiatry originated in the „mental hygiene‟ movement, whose followers

    succeeded after World War II in placing social factors firmly on the agenda (even though they

    shied away from asserting direct links between social conditions and mental disorders).

    At the Amsterdam conference, historians such as Jonathan Andrews and Colin Jones argued that Laing had borrowed ideas from psychiatric colleagues without attribution and

    constructed “a heavily contrastive version of his opponent”, in which progressive and innovatory

    elements within mental health care were ignored. Instead, all attention was focussed on

    Kraepelian intramural psychiatry. Anti-psychiatry seemed to reject out of hand the possibility

    that biological factors might play some role in some conditions. The critique of intra-mural

    psychiatric care was one-sided and indiscriminate, and lent itself all too easily for misuse by

    policy-makers looking for ways to justify closing the hospitals and turning psychiatric patients

    on to the street. In the crude and over-simplified version which activists often adopted, anti-

    psychiatry presented a challenge which the psychiatric establishment had little difficulty in

    dismissing. One could even argue (though I don‟t really have the heart to do so) that by creating

    a rift in the progressive forces within mental health care, anti-psychiatry ultimately strengthened

    classical psychiatry and made it easier for the Kraepelinians and their allies in the pharmaceutical

    industry to make their spectacular comeback at the end of the twentieth century.

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Main ingredients of the critical movement in mental health

    If there is such a thing as critical psychiatry, what are its main features? As I have said above,

    theological arguments about what this movement „really‟ is are a bit pointless: a movement is

    whatever its followers make of it. I can only describe the two themes which seem to me, from

    my own personal position, to be central.

Positivist versus interpretative approaches

    Critical psychiatry is not so much directed against a biological approach to mental illness as

    against a one-sidedly positivist approach. Under „positivism‟, I understand the programme of modelling the human sciences on the natural sciences. A positivistic approach to environmental

    factors, in which these factors are regarded as blind forces impinging on a passive subject, is no

    less objectionable than a biological approach.

    This issue is related to a very fundamental distinction between modes of knowledge, that

    between explanation and understanding (often referred to by the German terms erklären and verstehen).

    a) A positivistic approach looks for causal explanations of human behaviour (erklären),

    using the notions of cause and effect. It usually starts from observed correlations and the

    laws or regularities which can be abstracted from these.

    b) An interpretative approach regards people as actors or subjects who actively interpret

    their own experience and who act in meaningful ways. Understanding people (verstehen)

    is a matter of finding out “what they are up to” or “what they are trying to say”. The

    starting-point of such an approach is the person‟s subjective experience (what they say

    and feel); the social context of action plays a crucial role in this approach.

    Having been fascinated for years by the pervasiveness of this split, I find it convincing to

    regard these two approaches as two components of the mentality which characterises European

    thinking since the Enlightenment. The positivist approach views people as objects and is linked to the drive to manipulate - to uncover the laws governing things and people, and to use this

    knowledge to bring them under control. The interpretative approach is concerned to emancipate to help people explore and express their subjectivity.

    Many of the criticisms directed against classical psychiatry have been aimed at its habit of

    using a positivistic approach when according to the critics an interpretative one would be more appropriate. The „normalising‟ approaches which I reviewed in the first chapter of Critical Psychiatry (Ingleby, 1980) all have in common that they try to recover the „intelligibility‟ of

    behaviour or experience deemed by classical psychiatry to be merely symptoms of illness. In

    adopting this strategy, the critics are really saying that emancipation is more important than

    control. This makes it clear that in the last resort, we are not concerned here with an argument

    about what is „really‟ going on, but with a clash of values.

    The defence of the positivist approach is of course familiar. An exclusively interpretative

    approach is based on a naïve, romantic notion of an entirely conscious and free unitary human

    subject. Moreover, control for instance over disease - is often desirable: getting a brain disorder

    under control which causes a person to act or feel in ways that are a threat to themselves and/or

    others, deserves to be regarded as form of emancipation. Mental illness is precisely the area in

    which an interpretative approach runs up against its own limits for it is precisely when behaviour does not seem to be intelligible in ordinary human terms that the psychiatrist is called

    in.

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    Only a few proponents of a „normalising‟ approach, such as Thomas Szasz, rejected the

    positivist approach out of hand. What most critics objected to in classical psychiatry was not that

    it sometimes used a positivistic approach, but that it always did so. For diehard Kraepelinians, interpreting the „human sense‟ of behaviour and experience was an intrinsically unscientific and

    untrustworthy activity. However, if you never allow yourself to look for intelligibility, you will

    never find it: you will end up failing to recognise the patient as a fellow human being. This was

    the core of the accusation which R.D. Laing levelled against classical psychiatry, and it is as

    valid now as when he made it. It is fundamentally misguided to think that either an exclusively

    positivist approach, or an exclusively interpretative one, could ever do justice to the complexity

    of real human beings. Whereas some aspects of a person‟s behaviour may have to do with a

    brain disorder, or the double Scotch they just consumed, many other aspects have to be

    understood in terms of their „human sense‟. All too often, however, we see that applying a

    psychiatric diagnosis has the effect of invalidating and marginalising the person as a whole. Just

    as in R.D. Laing‟s day, the most glaring examples of this occur in the case of schizophrenia.

    Patients and relatives of schizophrenics are routinely encouraged to regard the condition as an

    illness which totally robs the person who has it of their humanity. As a result, everything the

    patient does, feels or thinks is regarded as not making sense or, at best, suspect. In this way, the

    diagnosis becomes a self-fulfilling prophecy; for in a world in which nobody takes you seriously,

    it is impossible to lead a human life.

    Critical psychiatry, therefore, does not regard mental illness as a „myth‟; rather, it insists that

    an emphasis on biological determinants must never blind us to the possible human sense of

    people‟s behaviour and experience. This means combining positivist and interpretative approaches. An example of such a „mixed discourse‟, in the view of the philosopher Paul Ricoeur, is psychoanalysis. In fact, psychiatrists in their daily work like the rest of us

    unavoidably use a mixture of positivist and interpretative strategies. The latter, however, are

    mostly implicit and unanalysed: they consist of the „common-sense‟ interpretations which we continually use in order to negotiate social life (Ingleby, 1982).

The power of psychiatry and its role in society

    The conflict between positivist and interpretative paradigms is a long-standing one which, as I th century, it was referred to as “the crisis in psychology”. However, when the critical said above, seems inherent to modern European thought. Among psychologists at the beginning movement started questioning the social role of mental health interventions and the way of the 20psychiatrists exercised their power, it was introducing a relatively new theme into the mental

    health area.

    The most obvious abuses on which the critical movement focussed attention were the

    blatant infringements of human rights that occurred when psychiatric diagnoses were used to

    suppress behaviour which could be recognised as a valid form of dissent. The Soviet Union was

    notorious for submitting political dissidents to forced psychiatric treatment, including

    confinement, sedation and electro-shock treatment. Such „totalitarian‟ practices were roundly

    condemned as an abuse of power by Western psychiatric associations. However, critics of

    psychiatry in the West argued that many interventions which were accepted as routine also

    amounted, in fact, to a comparable abuse of power. The gist of the critique was that whereas

    mental health interventions are carried out in the guise of benevolence (“it‟s for your own good”),

    to a greater or lesser extent they serve other interests: those of the profession, for example, or

    (more generally) those of social groups which have a vested interest in maintaining the status

    quo.

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    Feminist authors attacked the tendency to interpret the implicit protest of a „depressed‟

    housewife against her role as a purely endogenous disorder, to be treated chemically or surgically.

    Classical, reductionist asylum psychiatry was most vulnerable to this type of criticism. However,

    even when the relationship between therapist and client is less authoritarian and „top-down‟,

    subtle forms of pressure can be used to invalidate non-pathologising interpretations of behaviour.

    Kathy Davis (1986), in a classic paper on „problem reformulation‟, showed how subtly clients in

    therapy could be persuaded to drop their own interpretation of their problems in terms of their

    social situation, in favour of the „intra-psychic‟ explanation favoured by the therapist. Necessary to the success of this operation (also known as “blaming the victim”) is the systematic neglect of

    the meaningfulness of behaviour, and of the social context which is crucial to its understanding.

    It was not only the misuse of power in individual cases that gave rise to criticism.

    When social, moral or political problems are redefined in terms of „mental health‟, as has

    happened increasingly over the last 150 years, they are as it were removed from the public

    domain; mental health professionals becomes arbiters over whole areas of human life which

    were previously treated as matters of general concern. This shift of power has been referred to

    as „medicalisation‟, „psychologisation‟, or (by Habermas, 1987) „colonisation of the

    lifeworld‟. Because such matters are now regarded as matters of professional expertise, they

    are removed from the sphere of lay discussion and become the province of specialists. Peter

    Conrad (1980) coined the term „medicalisation‟ of deviance to cover this process.

    For example, the contents of the DSM (American Psychiatric Association, 1952, 1968,

    1987, 1994) is drawn up and ratified by panels of experts from the psychiatric profession.

    Diagnoses of mental disorder are supposed to be value-free, i.e. independent of the particular

    social norms which the person making the diagnosis adheres to. Yet all diagnoses contain, of

    necessity, a large number of implicit value-judgements. The committees which draw up these

    categories and define their boundaries are, therefore, fixating and reifying social norms. The

    classic example of this is the case of homosexuality, which ceased to be classified as a disorder

    when the social climate in the United States became more accepting of it. But all psychiatric

    diagnoses require that a person‟s behaviour and experience be judged against norms concerning

    what is „reasonable‟, „understandable‟ or „acceptable‟. To deny that these norms exist, or to

    exaggerate the extent of consensus over them, is to ensure that the use of diagnoses as an

    instrument of social regulation goes unchallenged.

    The fate of the critical movement after the 1970’s In terms of my own career, the publication of Critical Psychiatry turned out to be „a bridge too

    far‟: the emphasis in my work on critical approaches to mental health proved to be a stumbling-

    block in my application for tenure at Cambridge University in 1980. The University did not

    further its reputation for objectivity and even-handedness when it appointed Sir Martin Roth at

    the time president of the Royal College of Psychiatrists, and a vehement defender of classical

    psychiatry to the committee which was to consider my application (see Sedgwick, 1981). In

    any case, the writing was on the wall: the era of Thatcher and Reagan ushered in a period of

    diminishing academic freedom and a vehement backlash against the social criticism of the

    1960‟s and 1970‟s.

    This backlash was clearly discernible in the field of mental health, as social

    approaches came increasingly under attack and classical approaches to diagnosis and

    treatment began a triumphant return to power. The notion that all mental disorders were

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essentially brain diseases became more widely accepted than ever before. Massive investment

    in research and public relations by drug companies ensured a comfortable place for the

    biomedical model as front-runner in the field: psychoactive medication moved „up-market‟

    and became a culturally accepted response to the stresses and strains of modern life. „Talking

    treatments‟ came to be regarded as wasteful and ineffective. Against the background of

    continual reorganisations in the health services, psychiatrists edged their way back to the

    dominant position which they had enjoyed before the heyday of interdisciplinary approaches

    in the 1970‟s.

    The steadily increasing financial squeezes of the 1980‟s and 1990‟s were another

    factor obliging mental health services to streamline and rationalise their procedures.

    Standardised, „evidence-based‟ approaches were implemented and the DSM became the

    conceptual grid for mental health services in most Western countries, thus consolidating the

    hold of the Kraepelinian model. In principle, the present-day stress on „evidence‟ is healthy –

    but in practice, the research paradigms used to evaluate theories and treatments tend to be

    positivistic ones drawn from the biomedical field. As a result, competing approaches are

    marginalized still further. Little attention is paid to individual differences, while minority

    groups tend to be excluded from clinical samples. Whatever does not lend itself easily to

    quantitative research, such as the effects of intensive, long-term therapies, is regarded as non-

    existent. In this way we have reached a situation in which mental health is dominated by a

    streamlined „no-nonsense‟ approach, which many dissatisfied users and professionals regard

    as the biggest nonsense of all. Moreover, the tendency to „medicalise‟ or „psychologise‟

    problems has become so widespread that even the British Medical Journal devoted a special issue to the dangers of unnecessary medicalisation (BMJ, 2002).

    As far as my own career was concerned, I was fortunate enough to be able to move to

    a chair in Developmental Psychology at Utrecht University in The Netherlands, where to

    my relief I discovered that the critical movement was still in full swing. Until 1990 my

    group and I were able to carry out a wide-ranging programme of research on the increasing

    social influence of psychiatry and other „psy‟ disciplines. In its scope, this work went beyond

    the „critical psychiatry‟ which I had previously been involved with. Moreover, I discovered

    that many of the ideas I and others had previously taken for granted were now regarded as

    misguided and outdated.

    What was at stake here was the shift from a neo-Marxist approach to a poststructuralist

    one, and the central issue concerned the concept of power. The critical movement had talked

    about interests and raised the question “whose side are you on?”. It saw power fundamentally

    in terms of repression and attacked professional notions as „ideology‟ – attempts to pull the wool over people‟s eyes. But according to the French „post-Marxists‟ and their followers, who

    were chiefly inspired by the work of Michel Foucault, this way of looking at power was

    inappropriate and ineffective. It is the discourse of psychiatrists and psychologists that has power, not their profession; to the extent that this discourse is socially accepted, it structures

    the way in which people give sense to and live out their lives. The important kind of power in

    the modern state, in other words, is not repressive but productive. The „psy complex‟ does not undermine people‟s interests; rather, it defines those interests. It does not distort reality, but

    constructs its own truth. The followers of Foucault, of course, were also active in Britain, and

    I soon discovered that in their view, books such as Critical Psychiatry were not part of the solution at all, but part of the problem (see Adlam & Rose, 1981).

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    Much of my work in the 1980‟s (e.g., Ingleby 1983, 1985) was devoted to trying to reconcile these conflicting frameworks with each other. The Netherlands provided an ideal

    setting in which to study the transition from a traditional society, in which many aspects of

    people‟s lives were governed by religious authorities, to a fully „modern‟ one, in which the

    influence of „psy‟ professionals was wide-reaching. Whereas in Britain and the USA, this

    transition took place gradually and almost imperceptibly from the end of the nineteenth

    century onwards, it did not take place in The Netherlands until the 1960‟s; and when it did

    take place, the effects were very visible. The oft-repeated cliché that psychology and

    psychiatry are „religions‟ and mental health professionals „priests‟ becomes, in this context,

    very meaningful. An important role in smoothing the transition from religious to

    psychological authority was played by figures such as Kees Trimbos, the Catholic psychiatrist

    who succeeded in explaining the ideals of the Mental Hygiene Movement (optimal adaptation

    and self-fulfilment) in terms that would be acceptable to the church authorities. According to

    Trimbos, good mental health was in no way incompatible with true religiosity; on the contrary,

    it was a precondition for it (Abma, 1981).

    During the 1980‟s, my colleagues and I at Utrecht carried out studies of child protection agencies, youth work, family health care, infant care, magazines for parents, day

    nursery provision, and drug policy. This research showed, indeed, that the concept of

    „repressive‟ power did not give much insight into these modern phenomena. Quite the

    contrary many lay people experienced the replacement of religious discourses on the question “how to live?” by psychological ones as a liberation. New concepts and attitudes

    were eagerly assimilated by the general public, a process which the sociologist Abraham de

    Swaan and his colleagues (Brinkgreve et al., 1979) dubbed „proto-professionalisation‟.

    Modern professionals acquired their power in far more subtle ways than the white-jacketed,

    authoritarian psychiatrists of old. Moreover, one could not view psychiatrists apart from the

    mental health system as a whole; and this system itself had to be seen as part of a larger „psy‟

    complex, involving many professions and many forms of influence..

    By the beginning of the 1990‟s, however, the backlash against critical social research had reached Holland as well, and the group I had been working with was disbanded. Luckily,

    I soon found another way of carrying on critical work on the mental health services via the

    topic of migrants, refugees and ethnic minorities. As I mentioned at the outset, my interest in

    migration was stimulated by my own experiences; I also came in contact with highly

    dedicated and inspired individuals who were working to improve provisions in The 2Netherlands for these groups. Although at first this „interculturalisation‟ movement seemed

    to me rather uncritical - many people in it seemed to assume that providing more mental

    health care was by definition a good thing I gradually came to realise that many of the

    themes of „critical psychiatry‟ had, consciously or unconsciously, been adopted by it. This is

    what I will now try to illustrate.

    The movement for transcultural mental health care

    The issue of culture and mental health has come to the fore in the last quarter century, both in

    relation to service provision in non-Western countries and in the context of multicultural

    (Western) societies. What factors account for this recent rise in interest?

2 The word „interculturalisation‟ is not used, as far as I now, in the USA or Britain. It is a useful Dutch invention

    which refers to the adaptation of services (education, health care etc.) to the needs of a culturally diverse

    population.

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    Firstly, with the globalisation of the world economy, Western approaches to mental health are being exported to other areas of the world and are having to be adapted to local

    conditions. This is leading to more awareness of the cultural relativity of the concept of

    „mental health‟. Secondly, over the last 35 years the volume of global migration has doubled.

    One in 30 of the world‟s population is now a migrant and there is a strong chance that the

    mental health services available to them will have been developed for a population culturally

    different from their own. In Western European countries, 8-10% of the population is of non-

    European origin; the problems of providing adequate service provision for this group cannot

    be ignored any longer.

    But (secondly) numbers alone do not create a need for reform: attitudes to migration and cultural difference also play a crucial role. In this respect, we can distinguish three

    different ideological periods.

Colonialism

    In the colonial era, „race‟ was the key concept and a clear hierarchy was presupposed, with

    Northern European whites at the top. Psychiatric descriptions focussed on bizarre or exotic

    phenomena and were constructed so as to highlight differences between races, non-whites being

    described as far closer to animals than whites. The one exception to this tendency was Kraepelin,

    whose aim was to show the universal validity of his theories; he, therefore, set out to look for

    similarities and not differences between races.

Assimilation

    The excesses of the Nazi‟s during World War Two gave racism a bad name (although it must

    never be forgotten that the belief in racial hierarchies was also deep-rooted in the U.S.A. and

    Britain). The war also hastened the break-up of the colonial system. In the post-war climate of

    economic expansion, social mobility was encouraged and more emphasis was placed on the

    influence of environmental factors than on genetic ones. „Culture‟ replaced „race‟ as a descriptor

    of diversity between and within populations. Rates of international migration increased.

    However, policies continued to emphasise the importance of cultural homogeneity and the superiority of white, middle-class culture. Migrants were expected to assimilate and

    programs were developed to remedy the „cultural deprivation‟ of minorities. At the international

    level, the WHO adopted a universalistic approach to medical research and service provision, in

    which Western theories and practices were assumed to be applicable in all corners of the world.

    In this period, therefore, there is little pluralism to be found in psychiatric theory and practice.

    Mental health care remained the province of whites, and minorities were hardly to be found at

    any level as practitioners, researchers, teachers, students or research subjects. Even as clients

    they tended to be under-represented.

Multiculturalism

    In the 1970‟s, the shortcomings of monocultural assimilation policies became increasingly

    apparent. Migrants and ethnic minorities did not, by and large, assimilate to the dominant

    majority culture, but instead learned to value and defend their own culture. Monoculturalism did

    not create harmony but antagonism, because it placed large sectors of the population in the

    category of second-class citizens. Multicultural policies, based on the notion of integration rather

    than assimilation, were developed in which minority groups were encouraged to retain their

    cultural identity. Multicultural policies were first introduced in the traditional migration countries

    (Canada, the USA, Australia) during the 1970‟s and were gradually adopted by some European

    countries in the 1980‟s and 1990‟s. „Cultural relativism‟ became more widely accepted,

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replacing the notion of Western supremacy. Even the WHO started applying anthropological

    insights and began to acknowledge the validity of non-Western medical systems. (It is no

    coincidence that the intellectual movement known as „post-modernism‟ attracted many followers

    in this period.)

    Clearly, it is only in a climate of „multiculturalism‟ that efforts to improving services for minority populations can get off the ground. As long as notions of (Western) racial or cultural

    supremacy dominate, such efforts will be disapproved of. A policy of compulsory assimilation is

    diametrically opposed to the goal of adapting service provisions to the needs of minorities. The

    resurgence of monoculturalism in many Western countries during the past few years is therefore

    a grave threat to the „interculturalisation‟ of health care. In Holland this has taken concrete form:

    the present government has discontinued subsidies for this activity, arguing that the

    responsibility for migrant health lies with the migrants themselves.

In what follows, I will outline various strands in the movement to improve mental health care for

    migrants and ethnic minorities.

Topics in transcultural mental health care

Remedying ‘ underconsumption’ of care

    One of the earliest arguments for paying special attention to mental health care for minorities

    was not, in essence, a „critical‟ one at all: it was the observation that members of these groups

    were simply not coming for treatment. The problem was inaccessibility: information about the

    available services was not reaching minority users, or they were not being referred by their GP‟s.

    To the extent that these users had an image of the services available, it was a negative one.

     At the most basic level, highlighting this problem does not reflect a critical attitude. One

    may be concerned about the fact that BBC television programmes are hard to receive in South

    Wales, but this does not make one critical of the programmes themselves. On the contrary, the

    assumption would appear to be that the more people watch the programmes, the better! That,

    indeed, seemed to be the attitude of some workers at the start of the „interculturalisation‟

    movement: the good news about mental health must be brought to all sectors of the community.

     However, improving accessibility soon becomes a critical affair. What if it turns out that

    the reception of BBC programmes in South Wales is perfectly adequate, but people are simply

    not tuning in to them? This analogy makes it clear that accessibility cannot be improved as long

    as the satisfaction with services is low. Some of the negative images of mental health services among minorities may be misguided such as the notion they are only there for the insane but

    others are based on bitter experience. To a certain extent, information campaigns and folders

    printed in different languages can remove misunderstandings and ignorance, and thus reduce the

    threshold for seeking professional help: but as long as the help is experienced as inadequate,

    there will be resistance to using the services.

Focussing on the social and psychological problems of migrants

    Another theme that was already present from the beginning of the „interculturalisation‟

    movement concerned the stresses to which migrants were exposed. Health care workers in the

    poorer areas of the large cities saw at first hand that the conditions in which many migrants were

    living were causing widespread physical ill-health and mental suffering. To start with, there were

    the problems of migration itself the loss of one‟s familiar world, broken relationships,

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