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Janet Feigenbaum1 and Malvinder Matharu2

1 Senior Lecturer UCL; Consultant Clinical Psychologist,

Strategic and Clinical Lead for Personality Disorder, NELFT
2 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 about

how unhappy she was. When she arrived the receptionist
rang her uncle to say she was at the surgery. Her mother
and uncle came to the surgery during her appointment.
Her GP told them she had been self harming. She was
to India.”

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
Interviews: 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
Both about mental health and about PD
• the community
• GPs
• religious leaders
• community
Contributing factors
• language
• media
• generations since
• schools
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
• 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
• 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 act
how you are it comes back to your family, everything comes back to your
Concepts of Self Harm/ D & A

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

• Go to GP for pills (medical

• Black magic / evil spirits
• go to spiritual leader for
• 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 talk
to anybody.”
“ … had a fantasy of Jinns, which are evil spirits trying to take over my
• 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
“.. my GP is a Muslim… he might be Asian Dr. but he could be very
Fear / Stigma
• not being seen seeking help outside the
• 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 openly
acknowledges 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 to
the extent and talked about widely…”
Other themes

• Guilt – sense of failure

• Anger – why me?
• Loyalty
• Betrayal (of the family)
• Educational differences
• Age / generation
Conceptual Issues

• collectivist culture
• external racism
• internalized
• cultural
• spiritualism
Solutions Generated

• Awareness
media – Asian television
Asian newspapers / magazines
Theatre – schools, community centres
Lunch clubs
Social clubs
GP training
Religious leaders (? Highly controversial)
Solutions Generated (cont)

• Don’t tackle PD – tackle well

exercise groups
lunch groups
social clubs
Solutions Generated (cont)

• Provide confidential / discreet

in leisure centres
in community centres
in schools

hire staff NOT from local area

Solutions Generated (cont)

• Staffing and informing

Asian staff
Asian female staff
all 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 from

local Religious Leaders
• The male Asian community
• First generation immigrants
• National racism
• Problems with classification for non-
• Language