Scholarly article on topic 'Culturally determined care goals and the efficacy of statutory services'

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Academic research paper on topic "Culturally determined care goals and the efficacy of statutory services"

International Journal of Qualitative Studies on Health and Well-being

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Culturally determined care goals and the efficacy of statutory services

Nazir Hussain

To cite this article: Nazir Hussain (2006) Culturally determined care goals and the efficacy of statutory services, International Journal of Qualitative Studies on Health and Well-being, 1:3, 149-158, DOI: 10.1080/17482620600756080

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International Journal of Qualitative Studies on Health and Well-being. 2006; 1: 149-158 Taylor 8«. Francis

Taylor &. Francis Group


Culturally determined care goals and the efficacy of statutory services


Whitby, Ontario, Canada


This article describes the culturally determined understandings of good mental health and distress of older Pakistani-Punjabi immigrants in Britain, and of how these beliefs may determine specific goals and needs during the help-seeking process for distressed minority ethnic service users. This includes a discussion of how these beliefs determine the perceptions of appropriateness and efficacy of statutory treatment options. The data is drawn from a qualitative, largely interview-based study of Pakistani immigrants, statutory healthcare service providers, and traditional Pakistani healers in Northern England. The study aimed to assess the reasons for the low uptake and apparently poor efficacy of statutory services provided to the immigrant group, despite a high prevalence of distress in this group. The study found that interaction (usually surgery consultation) between service users and providers was unsatisfactory for both parties. The unsatisfactory results of service use for both providers and users appeared to be rooted primarily in cultural misunderstandings that led to divergent goals, and thus divergent approaches to service use/provision behaviour. It is hoped that this article may serve as a guideline for the development of more appropriate and effective services for similar groups.

Key words: Transcultural, worldview, mental healthcare services, British-Pakistani, south Asian, mental health


The current philosophy of mental healthcare service provision in Britain recognizes universal entitlement to adequate and appropriate healthcare services for all residents of the UK; this is reflected in the current National Framework for Services—Mental Health (2004). A consensus concerning the design and delivery of mental healthcare services is that standard clinical methods of healthcare service are not necessarily appropriate for minority ethnic groups. Studies such as those of Patel (2001), Fernando (2002) and Atkin (2004) suggest that applying the standard Western healthcare models in a "colour blind'' manner to minority ethnic groups is ineffective and potentially harmful. While steps have been taken in the UK to offer services that are effective through a doctrine of development and delivery of "culturally sensitive'' or "multicultural" services, the reality in clinical environments tends not to reflect it (Watters, 1996; Atkin, 2004). This is shown by a low uptake of statutory services by minority ethnic groups (Beliappa, 1991), dissatisfaction by minority

ethnic groups with available services (Williams, 1996), and poorer self-evaluations of well-being by ethnic minority groups (Office for National Statistics, 2002).

The failure of statutory services to meet the needs of minority ethnic groups places them at a distinct disadvantage, not only in attaining good health, but also in their standard of living. Placing this group at social disadvantage through the collective failure of a statutory institution constitutes institutional racism as described in the McPherson report (McPherson, 1999).

It is argued that traditional methods of providing care to minority ethnic groups tend to be successful where Western methods fail. It is argued that an integration of these methods into larger treatment programmes would be an ideal means of overcoming obstacles in providing effective care to minority ethnic groups (Obeysekere, 1985; Patel, 2001; Fernando, 2002). However, the reasons why these methods succeed while others fail are not precisely understood. The study presented here is a qualitative

Correspondence: Nazir Hussain, 10 -10 Bassett Blvd, Whitby, ON L1N 9C3, Canada. Tel: +1 905 666 9706. E-mail: (Accepted 13 April 2006)

ISSN 1748-2623 print/ISSN 1748-2631 online © 2006 Taylor & Francis DOI: 10.1080/17482620600756080

attempt to understand the reasons for the low uptake of services by a specific minority ethnic group, including the reasons why the group found services unacceptable and what they believed could be done to improve the services. During the research process, evidence concerning why statutory services failed to address the needs of the minority ethnic group came to light, and became the central focus of the study.

Contemporary views regarding the efficacy of Western services applied to minority ethnic groups

It has been argued in various manners by Kleinman (1978), Obeysekere (1985), Graham (1992), Ellis (2001), Patel (2001), and Fernando (2002) that mental distress is inherently shaped by worldview; cultural beliefs about what behaviours constitute normal mental health and distress determine which life events evoke distress and the shape that distress takes. Graham and Fernando argue that the appropriate means by which distress is remedied is equally determined by the worldview of the distressed; in the case of non-Western minority ethnic groups in Western host societies, Helman, Fernando, and Patel argue that ''culturally congruent'' methods of therapy are necessary for effective treatment.

Fernando (2002) claims that traditional means of healing mental distress are frequently both more effective and appropriate than Western psychotherapy. Patel (2001) observes that the ''cultural congruence'' of ''therapist'' and client is the strongest predictor of effective care. Kakar (1982) argued that healing methods traditionally employed by non-Western groups were more effective than Western psychotherapies at relieving distress within that group because they were rooted in their worldview. Helman (1994) suggests that Western healthcare applied to minority ethnic groups is prone to misdiagnosis and potentially harmful strategies. Fernando (2002) and Atkin (2004) suggest that the use of Western psychotherapeutic methods in providing care to minority ethnic groups may cause harm through the perpetuation of racist attitudes engendered in Western healthcare methodologies and reinforcing colonial power dynamics.

While these arguments and observations, and similar ones from other sources, form the canon of modern ''culturally sensitive'' healthcare provision standards such as the National Services Framework for Mental Health (Department of Health, 1999), they provide few qualitative descriptions of the cognitive processes of either minority ethnic service users, or the service providers they engage.

Study aim

This study originally aimed to elucidate why firstgeneration Punjabi immigrants from Pakistan in a city in Northern England had one of the lowest voluntary uptake rates of statutory mental healthcare services in the area, even though they were the largest minority ethnic group in that region. As the study developed, the experiences of distressed Punjabi immigrants were collected and examined. Their perceptions and experiences of statutory services combined with their cultural narratives of health and distress painted a distinct picture of the mechanism by which the Western services failed to meet their needs as well as the manner in which traditional healing methods succeeded in doing so.


The study was based primarily on multiple loosely structured interviews designed to elicit personal narratives regarding the experience of mental distress and help seeking both from traditional and statutory care sources. The data were augmented and triangulated by observational and anecdotal data collected during the research process.

The study group

The study incorporated thirty-three distressed first-generation Punjabi immigrants from Pakistan (16 men, 17 women) aged 55 years and above, all but two of whom who were either involuntary users of statutory mental healthcare services or clients of local traditional Pakistani healers. The Punjabis were selected for a combination of age, sex, region of origin, and the presence of distress. Age is a complex and relative construct among this group; they defined themselves as ''elderly'' based on the age of their children, and thus their traditional roles in the household, rather than chronological age; the respondents' ages ranged from 55-62 years, but characterized themselves as being of the same age group. Distress was determined through their use of services (traditional or statutory) and the verification thereof by their care-provider of choice (with permission).

The researcher accessed the statutory service-using respondents via community care programmes. The programme managers aided the researcher in respondent selection, ensuring that respondents with severe mental or physical illnesses outside of the purview of the study were not recruited (see ethics, below). Three people were dropped from the initial sample because of health complications that arose during the selection process; the researcher did not

feel it would be conscionable to risk aggravating their illness.

The traditional healers' clients were introduced to the researcher through one of the local pirs (spiritual leaders). As the pir has sworn an oath to protect the mental and spiritual health of his clients, he would not make introductions until he had interviewed the researcher about the nature, intent, and methods of the study, and was satisfied that the researcher would apply the same ethnical safeguards to his clients as to interviewees selected through social services. The pir also performed an informal background check on the researcher through his Pakistani kinship network.

Data collection

Narrative-pointed questioning was used to elicit biographical narratives on the events leading to their distress, the form of their distress, beliefs regarding its causes and appropriate remedy, and their experiences in engaging both statutory services and traditional healers. These questions were designed to be as open-ended as possible, for example ''Can you tell me about the first time you felt distressed?" This allowed the interviewee to interpret the question as broadly or narrowly as they liked, and to offer their own categories and ideas about distress in narrative form.

Subsequent interviews were used to elicit narratives on specific themes that were emphasized by respondents during the initial narratives. For example ''can you tell me about a time where you used sabr (pious endurance of suffering) to help you feel better?'' During the interview process, the researcher also made notes based on observations made during the interview and research process. These data ranged in complexity based on situation. For instance, the researcher made complex notes during quasi-participant-observation in the statutory community care programmes about the attitude, body language, positioning, and interaction of the clients and staffs of the programmes. Body language, comfort level, religious gestures or emotive actions were noted during the interview process. Before the interviews, or during other home visits (which were part of traditional protocol), notes were made about family interaction, the layout of the home, and the semiotic intent thereof. The researcher also spent some time in the community in which the respondents lived in order to gain a ''feel'' of the community and their general social and religious environment.

During the interview process, the respondents tended to share anecdotes, gossip, and comparative stories to highlight their own narratives. The researcher encouraged ''off topic'' discussion to

some degree during the interview process. These anecdotes often served to highlight the narrative of the respondent, enrich thematic and conceptual data, and served as a tool by which the researcher could gain a comprehensive understanding of the data.

In order to attain a balanced account of the interaction between help-seekers and care providers, interviews were undertaken with the seven GPs that carried the majority of the caseload of local Punjabi immigrants at the time, seven psychiatrists involved in the provision of mental healthcare to Punjabis immigrants, and seven Social Services managers involved in the design and delivery of local mental healthcare service programmes. Four local traditional Pakistani healers were also interviewed.

Data analysis

Data analysis occurred concurrently with data collection; each interview and observational data was recorded in a shorthand form and transcribed into longhand immediately after the interview. Once the notes transcribed various quotes and observations that pointed to an incipient theme they were re-recorded in a separate set of notes (such notes on the theme of sabr, traditional family structure, or role-related dysphoria) where they could be cross-referenced with information from other interviews. The goal of data analysis was to develop a comprehensive understanding through the triangulation of observational, repeated interviews, and narrative inquiry. The primary orientation of the researcher was not to confirm or deny an existing theory of data, but rather generate a theory and new conceptual categories through data analysis.

After the data from a given interview was recorded and categorized, the researcher would develop a ''working narrative'' that attempted to create a generalized explanation of the experiences of the study group, taking into account all of the themes and categories that had arisen over the course of data collection. The researcher allowed these categories and themes to emerge over a period during research. He made a note of emphasis, use of terminology, and points that the interviewees appeared to believe salient rather than attempting to impose categories on the data. In this manner the researcher could give the data a ''comprehensive treatment'' consistent with the ''Constant Comparative Method'' described by Silverman (2000), thereby adjusting to new categories and data as they arose and mitigating the risk of selective interpretation.


The ethical committees of both the University of Central Lancashire and of the local Social Services Directorate monitored the design of the study and its execution. The researcher, the ethics board, and the pir through which respondents were accessed (see above) were concerned about the potential exploitation of the study group due to a lack of understanding of the protocols of research, a power imbalance due to their status as a marginalized group, or language barriers. There was a concern that the group's well-being might be compromised during the interview process, due to the emotional strain of discussing their problems.

In order to ensure that the interviewees were made aware of the purpose and intent of the study, and their rights as participants, they were reminded in their primary language of their right to halt the interview, or cease participation at any time, at the beginning of every session. Respondents were given contact information for the ethics boards and encouraged to contact the board if they had questions or complaints regarding the study. In order to ensure mental and physical comfort interview sessions were limited in time, and spread over a number of sessions. Interviews were stopped whenever the interviewee showed signs of discomfort and resumed later.

Owing to the traditionally subordinate position of women in this group, the researcher was particularly concerned about the power dynamics that might arise in the interview, and their effect on the woman's willingness to contact ethics committees, request pauses or call an end to the interview. Female respondents were contacted, as per protocol, through a male family member, who was also present during the discussion of the purpose, intent and rights of participants in the study. A chaperone was always present in the house to ensure that the female respondent's comfort was observed and traditional boundaries of interaction maintained. The chaper-one was not permitted to remain in the same room during the interview, so that the respondent would not edit her narratives.

the protection of family (izzet) were the primary religious activity of a Muslim; God causes illness (through kismet,) as a punishment for the violation of roles. Well-being, formulated as ''Peace of Mind'' was predicated on adherence to gender roles, and the perception thereof in the community. Even the remedy of illness is formulated in terms of observing one's gender roles with a specific mentality (sabr). These beliefs may be seen as predictors of the attitudes and behaviours of this group when faced with distress, and in engaging both statutory and traditional service providers.

The use of statutory services, and the experience thereof, as well as the resulting attitudes towards those services are filtered through the lens of these religious beliefs. They create certain expectations of the means and content of service delivery that are not necessarily compatible with those of mainstream statutory services. Where the expectations, and thus the methods of help-seeking and service delivery are incongruent, it can create alienation, confusion, or further distress for both the service user and provider, and create blocks to providing appropriate

The punjabis' beliefs regarding distress

It is important to note that the concept of mental health as held by the Punjabi immigrants was not congruent with the Western concept. The term ''mental health'' itself, was problematic; Punjabis believed that ''mental'' problems indicated ''madness'', which was a punishment for sins. Implications that a Punjabi immigrant was not ''mentally'' healthy were taken as an insult. Most of the emotional states that Western care-providers would characterize as mild mental distress, such as depression or panic anxiety disorders, were seen as ''spiritual'' rather than ''mental'' disorders.

How do you know I'm mad? Have you scanned my brain? No, I am not mad and I will not see a mad person's doctor! (55-year-old male respondent

to his GP regarding psychiatric referral.)


A comprehensive understanding of the narratives of health and the experience of service use

The study groups' understanding of distress is encapsulated in their religious beliefs; the advent of distress and its remedies are structured around a number of religious concepts that consistently arose throughout the interview process. They believed that the fulfilment of gender roles (purdah) and

Distress: causes and remedies

The Punjabi immigrants believed that their distress was caused by God, either as a curse to punish them for sins or as a test of their faith. Life events that elicited their distress, especially intra-family problems, the experience of racially motivated crime, or material losses, were seen not as a cause, but an intermediate step in the causation of distress. They believed that the appropriate way to remedy their distress was therefore, to regain God's favour.

Re-establishing a traditional family structure, prayer, and practising sabr (see below) are the accepted means of regaining God's favour. Once an appropriate show of faith and obedience to God was achieved, it was believed that God could be enticed to rewrite the kismet of the distressed individual and his or her family.

A curse means the withdrawal of the blessing of God, and without [that blessing] even medicine will not work for sickness, money won't bring prosperity to the family, and the family will disintegrate; there will be troubles without reasons. (63-year-old female respondent.)

Kismet: fate as the cause of distress

Four concepts are critical to the Punjabi immigrant's beliefs regarding health and distress: kismet, sabr, purdah and izzet. Kismet can be translated as destiny: all events are predetermined by God, including health, illness, distress, and material wealth or woe; God changes one's kismet for better or worse depending on the virtue of the distressed. Distress is understood to be a part of one's kismet and cannot be relieved unless one's kismet dictates it. To complain about one's kismet or to take control of it through assertive action is considered a sin that invites greater distress or losses as punishment.

Kismet has significant impact on the way this group interacts with their environment. To make long-term plans, take assertive actions toward problem resolution, predict a positive outcome to an event, or to discuss one's emotions, family, or financial situation are all potentially violations. Accordingly, discussing one's mental health overtly, making use of a prescription, or in some cases, even choosing to see a medical professional for a problem could be interpreted as a sin that would make distress worse, not better.

Kismet also had some impact on the way in which services are perceived. Because medicine has no religious dimension; 31 of the interviewees believed that it would only be effective if God willed it to; some concluded that statutory services were therefore a superfluous. The remaining two respondents believed that using medicine rather than trusting in God alone would be a violation of kismet, and therefore a sin. All of the respondents believed that trusting in a statutory service provider without reference to God's Will, would be a sin. Some believed that GPs were incapable of anything beyond symptom suppression because they addressed material, not spiritual matters.

The belief that medicine was only effective when kismet permitted it led this group to use medicine

sporadically: they used it when their symptoms were severe. The medicine was therefore ineffective, and sometimes harmful. Most discontinued the use of prescriptions after a time. This reinforced the belief that GPs were ineffective in treating the (spiritual) cause of distress.

A combination of the belief in kismet and a mistrust of the government agencies prevented the study group from offering feedback on the appropriateness of the services offered to service providers. On the one hand, if they complained, they feared that they might be subject to withdrawal of income support. On the other hand, they feared that God might punish them for taking action rather than accepting their kismet. The local Social Services managers relied on feedback and complaints from minority ethnic groups to adjust programmes and determine the funding and scope of their delivery; without feedback to help them shape the services, they could only offer generic services to this group. Some of the Social Services managers were vaguely aware of the ''Catch 22'' problem this presented, but feared they would be accused of paternalism or favouritism if they changed their methodology to suit this group.

Sabr: endurance of distress as help seeking

Owing to the taboo against planning or assertive action, the study group used passive means of addressing distress. They believed enduring distress without complaint, regarding problems with stoicism, and observing one's gender roles piously, one can entice God to ameliorate distress and rewrite kismet. This practice is called sabr. Many of the interviewees believed sabr was the only acceptable course of care; other methods of help seeking would violate kismet.

The Punjabi immigrants believed that care should facilitate sabr; because problems such as insomnia, physical pain, and severe emotional disturbances could disrupt the practice of sabr, their management was the primary reason for approaching statutory services. Care must also have a strong spiritual dimension in order to address the spiritual cause of distress, prayer, religious observance, or religious trappings such as recitation of the Qu'ran. Ideally, care creates or reinforces family unity, through courses of prayer or treatments in which entire family must participate.

They believed that appropriate care required unconditional acceptance by the caregiver, which they associated with an instant understanding and dialogue that did not necessitate discussing their problems overtly (which would violate sabr.) The barometer of effective care was their ability to make

the service user feel as if they were in a dialogue with God.

Sabr was always the initial recourse for this group when they first experienced distress. Owing to the requirement for silence and stoicism, it was rare for the individual to seek any other form of help, even from family members. Sabr alone was usually insufficient to relieve distress; over time, members of the study group would develop secondary distress-related problems, such as insomnia, pain, high blood pressure, or diabetes, at which point they would approach GPs.

Some of this group believed that the GPs might be able to act like traditional healers and relieve their distress, but most used GPs only as a means of facilitating sabr; by reducing the secondary symptoms of distress, they believed they would be able to continue practicing sabr and thus regain God's blessing. Regardless of the initial belief, the imperative to suffer without complaining about one's kismet prevented them from communicating anything other than their physical symptoms to the GP; to discuss their family situation or emotions would violate sabr and kismet, thus perpetuate the distress. The gender roles to which the group subscribed (encapsulated in izzet and purdah) had additional impact on the communication between this group and GPs.

Purdah: gender ''modesty'' and role-fulfilment as the determinant activity in distress and it's amelioration

Purdah encapsulates most aspects of Punjabi gender and familial roles, if one does not execute one's roles as expected one is in violation of purdah. For women, purdah required silence; good daughters, mothers, or wives are expected to be a helpmate for the men of the household; ''burdening'' men of the household with complaints would be counteractive to their roles. To complain to younger women in the household could be seen as a sign of weakness or immaturity, thus an inability to fulfil their roles. Complaining to older women was permissible; however, most female respondents were the oldest women in the household. Speaking to people outside the home, except in the context of certain religious gatherings, could be seen as a sign of shamelessness or wantonness; women were expected to interact exclusively with their own household and family.

For men, purdah requires dominance; men are expected to be the protectors of the women and younger men of the family. For older men to complain about problems to younger ones would be a sign of an inability to protect. For a younger man to complain about distress is to show immaturity and unmanliness to their peers.

For both genders, this means that complaint must be restricted to certain family members, or not done at all. A respondent in a superior position to the rest of their family (such as a mother or father) had to worry about causing anxiety about the family stability if they complained. Interviewees in a subordinate position (a wife or daughter) had to worry about appearing unfit for their roles. This often meant that there was no appropriate person within the family to confide in. Women were prevented from discussing problems with the men of the household or seeking help outside the household by taboos about appearing ''sexually uncontrolled''. For men, the fear of appearing weak or unmanly was not only a violation of purdah but also threatened the honour of the entire family (see izzet below.) This often made sabr the only option for relieving distress.

The use of statutory services, especially GPs was problematic in light of purdah. Traditional healers existed in a particular religious ''space'' wherein talking about problems to them was not a violation of purdah. The study group and the healers also shared a set of idioms, through which distress could be discussed covertly, thus padding against purdah violations. While saying ''my daughter's refusal to accept an arranged marriage makes me sad'', might still be a violation of purdah, a traditional healer could be relied upon to understand that ''I feel as if my heart were burning'' indicates a state of emotional distress caused by family conflict. Statutory service providers had neither access to these idioms, nor did they exist in a religious space (many respondents believed that GPs existed in an ''anti-religious'' space); therefore, the respondents were uncomfortable talking to GPs about family or emotion. The GPs' attempts to take a case history were viewed as a threat to maintaining purdah.

Many of the Social Services Managers predicated their understanding of the culture of minority ethnic groups on feedback. The low uptake of statutory services and lack of feedback left these managers uninformed about the cultural milieu of the study group; they operated primarily on assumptions about ''Asian Culture''. These assumptions led them to believe that the low uptake of services and lack of feedback indicated that their families cared for this group at home, when actually requirements of purdah made it difficult for this group to gain family support.

Izzet: honour and family protection as the measure of balanced mental health

Izzet is best understood as family honour. In order to have good izzet, the community must perceive the family as being virtuous. Charity, favours,

gift-giving, participation in the local religious community, and arranged marriages to reputable families are the means by which izzet is improved. Izzet is lost through gossip, and the violation of purdah, when it becomes public knowledge.

Izzet is concentrated in the head of household. The measure of his worth as a man and as a member of the community lies in his izzet; a man who loses his izzet is considered less than a man. Edger (1960) and Gilbert, Gilbert and Sangerha (2004), observe that a family without izzet is excluded from the community to a greater or lesser degree, depending on how it is lost. Marriage proposals may be turned down, kinship support may be withdrawn, and the family may lose its ability to participate in the local system of reciprocity that ensures one's survival of prolonged sickness or disaster.

''If wealth is lost, then nothing is lost; if health is

lost, then something is lost; if izzet is lost, then

everything is lost'' (60-year-old male respondent).

When one family member violates purdah or is the subject of gossip, the entire family is therefore subject to distress over the loss of izzet. Even the threat of a loss of izzet can be a source of distress. Many of the respondents felt that the necessities of living in Britain posed a constant threat to their izzet. Having girls educated outside the home or having the women of the household work was often a necessity, but was seen as a compromise to their purdah, and thus family izzet. The perceived Westernization of one's children, especially in relation or arranged marriages, was usually the triggering event in the distress of this group. ''The purpose of life is to protect one's izzet'' (Pakistani Axiom).

Most of the group felt that GPs could not be trusted to maintain confidentiality; GPs were believed a potential source of gossip. Moreover, they did not believe a GP could understand the problems related to izzet or that they were beyond his scope; for example, there was no point in discussing distress related to a piece of gossip, as the GP could neither discontinue the gossip, not could he change the kismet of the patient and thus make the gossip irrelevant. The same religious ''space'' and shared idiom that made healers a non-threat to purdah also meant that bringing a problem to a healer (crouched in the right idiom) would not cause a loss of izzet.

This group's pattern of GP use was dictated by the preservation of izzet and the observation of sabr. The limitations that sabr, purdah, and izzet collectively placed on patient-GP communication with this group prevented GPs from the early detection of mental health problems. The GPs' diagnostic

methodology required patients to discuss emotional trouble or family problems before the GP could diagnose ''mental health problems'' and make appropriate referrals, both of which the study group refused to discuss. The group's beliefs in kismet often made the medical help that the GPs could offer them (painkillers etc.) ineffective, or undesirable. The respondents gained little or no relief from sabr and could not approach family members for help for fear of violating purdah and upsetting the whole family, because of the threat that violation posed to their izzet. Accordingly, the study group made frequent, increasingly unsatisfying visits to GPs for sabr facilitation. Those that did not find and make consistent use of a traditional healer would reach a crisis point, and then undergo compulsory admission into psychiatric care, followed by community care programmes.

The GPs often suspected that the physical complaints they were treating were indicative of ''mental health problems,'' but were unable to diagnose it because of the limited scope of dialogue. Attempts to get information on their patient's emotional state or family situation were met with resistance; the GPs often gave accidental offence with such inquiries. They were unwilling to alter their diagnostic methodology in such a way that they could reach a diagnosis of mental health without hearing key phrases from their clients; they felt bound by rigid bureaucratic guidelines and worried about malpractice allegations if they adjusted those methods.

The stigma attached to ''madness'' and ''ill mental health'' by this group created a special problem when engaging statutory services. The respondents believed that any association between a family member and ''mental health'' problems could be damaging to izzet, as the whole family would be assumed to have some connection to an unforgivable sin. Any referral that a GP made to a ''mental healthcare'' service was immediately seen as a threat to the family's izzet, and met with resistance.

Compulsory admission into a community care programme was seen as a fatal blow to one's izzet; the respondents who had been admitted to such programmes felt stigmatized; many described themselves as less than human, all of them were socially withdrawn, and most entered into a cycle of crises, compulsory psychiatric care, and further degeneration in health.

''Peace of mind'': normal mental health and its cultural formulation

The Punjabi immigrants aspired to a broad concept of spiritual well-being termed ''peace of mind." Peace of mind required a sense of optimism, an ability to

carry out religious duties, and fulfil gender roles. Family was of key importance to attaining and maintaining peace of mind: for the majority of the Punjabi respondents, a family in a traditionally accepted configuration, possessing good izzet, with each member carefully observing purdah, and with the blessing of God (no distress), was considered necessary to have peace of mind. The most common causes of distress among this group were various forms of disunity in the family, usually caused by the perceived Westernization of the younger generation.

The respondents that underwent compulsory psychiatric care often felt that their izzet was irreparably damaged and peace of mind, therefore, unattainable. They became socially withdrawn and reported feeling hopeless. The psychiatric care they were offered had little impact, and many felt the community care programs served to highlight their stigma, and thus caused their distress to degrade rather than ameliorate it. Most believed that using statutory services itself was in a sense sinful, and their association therewith was worsening the problem; they believed that only divine intervention could relieve their distress, and thus continued using sabr, although the required isolation and silence exacerbated their distress through loneliness.

The community care programmes were offered on a Western model that was often unhelpful; the clients were constantly exposed to the idea that they were ''mentally ill,'' which upset them further. The staff of several of these programmes appeared to believe that the beliefs of the respondents were the root of the problem, and encouraged the respondents to assimilate a Western model of health and illness; these attempts to ''educate'' the respondents were often traumatic and alienated them from the programmes.

Discussion of the results

The exceptional cases

While the beliefs of this group were often predictive of their use of services, and in general had a consistent pattern of service use until the point of crisis, the manner in which these beliefs were predictive of behaviour was not necessarily uniform. Two interviewees had a pattern of service use noticeably different from the other 31. The beliefs of these two respondents were still predictive of behaviour, but their service use pattern varied based on their ability to negotiate beliefs with the services presented based on a number of variant factors. It is plausible that all of the respondents had they access to the resources and education of this group, may have had patterns of service use more in line with the exceptional cases. Like the other respondents they

initially addressed their distress through sabr; and sought GP aid when distress-related problems inhibited sabr. Initial consultations with GPs were similar to those of the other immigrants; religious taboos prevented them from discussing family or emotional problems with GPs. They began the pattern of repeat visits to GP in order to facilitate traditional help seeking methods.

In both cases, the interviewee had access to information that was not available to the others; in one case the interviewee was given a pamphlet on depression in Urdu, while the second respondent's children (both healthcare workers) approached him. Once the information was couched in a manner they were comfortable with, they were able to negotiate that information with their own paradigm of distress. Both concluded that Western labels for their distress, and its causes and treatment, while not ''correct'', were ''functional''; although they did not directly involve God in the healing process through religious/ spiritual activity, both concluded that God was involved in the healing process by which Western medicine worked (i.e. by inspiring the GP or psychologist). Thus, by using Western medicine they could still address the spiritual element of distress.

... How could it be possible [for me] to have such fear and weakness without a medical reason unless I was possessed by a spirit? If I had a physical or mental problem it could have been treated, but how could medicine treat a spiritual problem? Man has reached the moon; if there were germs in my body it would have been easy to detect them. (56-year-old male respondent.)

Unlike the other interviewees, these two expressed satisfaction with the services of GPs and other statutory services. A number of factors distinguished these two exceptional cases from the other respondents, which may have improved their ability to negotiate between their culturally informed beliefs regarding distress and the Western model of (mental) health and illness. The most noteworthy differences between the exceptional cases and the other respondents were a combination of community of origin, education, linguistic ability, socio-economic status, and occupation.

The majority of the Punjabi immigrants were from rural areas of the Punjab. They were home educated in religion and the family trade; spoke little or no English and were functionally illiterate. While some reported having been considered relatively wealthy in Pakistan, the majority of the Punjabi immigrants interviewed had lived only little above subsistence level before immigrating. They tended to be either unemployed, working part-time in textile-plants, or in

community-oriented entrepreneurial enterprises, which limited their exposure to mainstream British culture. The exceptional cases were both raised in an urban environment, and had a post-secondary education. Both were the children of entrepreneurs who could maintain a higher than subsistence level lifestyle. Both had at least a conversational grasp ofEnglish, and could read and write a little English, as well as being highly literate in their mother tongues. Both of the exceptional cases worked in occupations that required a high level of contact with mainstream British culture (taxi driver and car dealer).

Care goals

The different groups involved in the help-seeking and care-provision process described here worked with an entirely different set of priorities rooted in their different philosophies of health care. These differing paradigms not only determined their understanding of how distress is caused and experienced, but also how it is appropriately addressed, and the priorities and goals of care.

The study group engaged statutory services expecting the GPs to provide them with a means of attaining peace of mind by facilitating sabr. The professionals assumed that like mainstream client groups, the study group would disclose their physical, mental, emotional, and family conditions in order to facilitate care. In 31 of the 33 cases, the failure of either group to recognize that they were working at cross-purposes to the other led to a breakdown in the provision of care. The Punjabis were ultimately required to either find alternative means of care (traditional healers) or suffer a severe emotional crisis.

Those that were admitted to compulsory psychiatric care observed a secondary breakdown of the care provision process; because the social services and mental healthcare communities were unaware of the beliefs and needs of this group, they offered services that were inappropriate; rather than receiving needed help. These programmes pushed these patients into a state of emotional shock and isolation, and subjected them to a series of programmes that perpetuated this state.

barriers by tapping into existing cultural taboos. In turn, these secondary and tertiary mental healthcare services could be structured in a way that could positively engage the group's existing resources. For example, a mental healthcare programme could be designed to make use of the ''religious space'' that traditional healers exist in to create a therapeutic environment where the services users would not feel that their izzet is being damaged through association with ''mental ill health.''

The failures of Western mental healthcare services in relation to other (immigrant) minority ethnic groups, as observed by healthcare researchers (such as Belliapa, 1991; Watters, 1996; Williams, 1996; Patel, 2001; Fernando, 2002; Atkin, 2004) may operate through a similar mechanism of a mismatch in the care goals of minority ethnic services users and Western mental healthcare service providers.

As only a minority of the Punjabi immigrants had the necessary background or resources to negotiate their care goals to receive effective and acceptable care from statutory services on their own initiative, it is necessary, if effective and acceptable care is to be offered to the whole group, that the research, understanding, and negotiation of care goals be implemented and have the necessary resources and background, i.e. the service provision end. This may be expanded to other minority ethnic groups as well. If we are to assume that the general trend of Western services failing to meet the needs of ethnic minority groups effectively is related to a mismatch of care goals, then that failure must also indicate that the majorities within those ethnic minority groups that are not served by mainstream Western mental healthcare also lack the resources to negotiate the mismatch in care goals on their own.

The onus to adapt to the care goals of ethnic minority groups as a whole rests on the service providers. To fail to do so is to place the ethnic minority group at a disadvantage in terms of the ability to receive meaningful care on a statutory level, which would fit the definitions of institutional racism put forward in the MacPherson (1999) report and the National Services Framework for Mental Health (Department of Health, 1999, 2004).

Conclusions and recommendations

In order for an effective and acceptable care programme to be offered to this group, it is necessary for information about their beliefs to be available, and diagnostic/design methodologies to be flexible. Had the GPs understood the reasons for the communications barriers, it might have been possible to circumlocute them and offer the relevant mental healthcare in a manner that would not create further


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