Janet Feigenbaum1 and Malvinder Matharu2

1 Senior Lecturer UCL; Consultant Clinical Psychologist, Strategic and Clinical Lead for Personality Disorder, NELFT2 Community Development Worker, NELFT

Scope of the Problem

Suicide rates high amongst South Asian Women (Bhugra & Desai, 2002)

Self harm rates high amongst South Asian Women (Husain et al., 2006)

0.5 % referrals to specialist PD service Asian (Geraghty & Warren, 2003)

12.5% local Waltham Forest population South Asian (India, Pakistan, Bangladesh)

1% referrals to local specialist PD service Asian

90% of Asian people referred to IMPART accept treatment

Initial anecdote – from an Asian receptionist

“An Asian friend of mine went to her GP to talk abouthow unhappy she was. When she arrived the receptionistrang her uncle to say she was at the surgery. Her motherand uncle came to the surgery during her appointment. Her GP told them she had been self harming. She was sentto India.”

Methodology

14 Semi-structured interviews (w/ vignettes) with Asian Mental health workers, community organizations staff, health staff, local authority, and service users

4 Focus groups Mental Health Staff Community Organizations Service users from Asian Counselling Service Sikh community group

Qualitative method – Framework Analysis

ParticipantsInterviews: All Asian: 1 service user, 1 domestic violence worker, 1 community day

centre worker, 1 support worker, 1 GP, 1 Drug & Alcohol worker 1 counsellor, 2 psychiatrists, 1 religious leader, 1 social worker,

1 young persons counsellor

Focus groups: Community groups: 8 Asian / 7 Caucasian faith ambassador, community managers, CDW, Support workers, therapists

Mental health: 4 Asian / 1 Chinese / 3 Caucasian psychologists, CPN, youth counsellors, OT, Dual diagnosis, psychotherapist

Sikh community centre: all female, Asian

Asian counselling service users: mixed male/female, Urdu/Punjabi, mostly Muslim

Lack of Awareness

• the community• GPs• religious leaders• community organizations

Contributing factors

• language• media• generations since migration• schools

Both about mental health and about PD

The Family

• do not speak of problems outside the family• fear of family being judged harshly• should contain self – not express emotions• not culturally acceptable to talk of personal problems• ignore within the family until severe• fear of being ostracized from the family• blame on the parents

“… there’s definitely a kind of hiding or covering up if there’s someone in your family with a mental illness… they are very quick to kind of point fingers and put them down…”

“… they don’t know how to ask their child ‘are you ok?’ Even though you might be crying in the corner, it’s not really the thing to do or say ‘I love you’.”

Respect / Shame / Izzat

• mental illness / PD brings shame on family• less marriagable (self and siblings)• damage to business• mental illness/ self harm/ drugs & alcohol dishonours the parents• Izzat has embedded concept of sexual honour• blame on the family - shaming

“How could you do that to your parents? How could you do that to anyone else?”

“ being a South Asian woman, the pressure is immense that how you acthow you are it comes back to your family, everything comes back to yourfamily”

Concepts of Self Harm/ D & A

• madness• crazy• disrespectful• unacceptable - taboo• Muslim – suicide is a sin (haram – not permissable)• react with anger not understanding• stigma• denial• bewilderment

Help Seeking

• Go to GP for pills (medical model)• Black magic / evil spirits• go to spiritual leader for guidance• pray more• herbal remedies

“Why are you going to sit there and talk to somebody about your problems, that’s your business, it’s your family’s business, don’t talkto anybody.”

“ … had a fantasy of Jinns, which are evil spirits trying to take over my body”

GPs

• seen as primary source of support/advice• rarely suggest psychological treatment• lack of awareness of PD• concerns about stigma for the community• poor confidentiality• know the family – fears of disclosure• patronizing to young women (mostly male Asian GPs)

“.. my GP is a Muslim… he might be Asian Dr. but he could be veryprejudiced.”

Fear / Stigma

• not being seen seeking help outside the family• not walk onto / into mental health site• will be spoken about• will know someone who knows someone• notes will be read and passed to family• talking will make it worse

“ I have a friend who has received counselling, … but she never openlyacknowledges that she’s had some sort of help… so she’s a bit ashamed of it”

“… if someone in Walthamstow [Asian] has a problem, the whole of Walthamstow is aware of it… even minor problem they’re exaggerated tothe extent and talked about widely…”

Other themes

• Guilt – sense of failure• Anger – why me?• Loyalty• Betrayal (of the family)• Educational differences• Age / generation differences

Conceptual Issues

• collectivist culture• external racism• internalized racism• cultural adaptation• spiritualism

Solutions Generated

• Awarenessmedia – Asian television

Asian newspapers / magazinesTheatre – schools, community centresLunch clubsSocial clubsSchoolsGP trainingReligious leaders (? Highly controversial)

Solutions Generated (cont)

• Don’t tackle PD – tackle well beingexercise groups

lunch groupssocial clubs

Solutions Generated (cont)

• Provide confidential / discreet servicein leisure centres

in community centresin schools

hire staff NOT from local area

Solutions Generated (cont)

• Staffing and informingAsian staffAsian female staffall languages and religious backgrounds

have former Asian service users talk to potential referrals and referrers

former Asian service users run groups

Major Barriers to Tackle

• Understanding and acceptance fromlocal Religious Leaders

• The male Asian community• First generation immigrants• National racism• Problems with classification for non-European

groups• Language