Kamaldeep Bhui is Professor of Psychiatry at the University of Oxford and Honorary Professor at Queen Mary University of London. He is internationally recognized for his groundbreaking work on cultural psychiatry, ethnic inequalities in mental health, and the social determinants of distress. In recognition of his contributions to mental health research and policy, he was appointed Commander of the Order of the British Empire (CBE).
He has written extensively on the grim reality of minorities facing higher rates of psychiatric detention and coercion. In an era of algorithmic checklists and time-pressured care, Bhui argues for reclaiming biographical listening and patients’ own stories and understandings. Without cherishing lived experience, clinicians lose meaning in their work and patients lose agency, trust, and hope. In this interview, we will discuss how our contexts and culture reach deep within us to inform our experience of pain, and to indicate what is abnormal, why we feel distress, and what it means to heal.
The transcript below has been edited for length and clarity. Listen to the audio of the interview here.
Ayurdhi Dhar: Dr. Bhui, people, especially in the U.S. and U.K., tend to think of culture as something other people have, like an accent. Even in psychological research, culture is often treated as an afterthought, which is why cultural competency training sometimes fails. Could you talk about some ways that a deep understanding of culture challenges our ideas of what is pathological or abnormal?
Kamaldeep Bhui: When someone’s having a distressing experience, it’s really difficult to communicate, and just by uttering some words, you already limit your experience. You think it represents your inner reality, but most of the time it’s an approximation.
For mental health practitioners, judging people’s internal mental states and making sense of them requires good communication, but it’s also a cultural orientation—how do I make sense of this? Also, the practitioner’s own positionality comes into play—how does my background, history, and identity enable me to listen to or not listen to particular aspects of this person’s painful story or heritage story?
Part of the challenge is that culture is a complex variable, including our laws, morals, supernatural forces, our relationships, our belief systems, our identity, how we see ourselves and our heritage, and how we position ourselves in relation to others around us. Mental health communication requires understanding what we hear and judge, whether it’s abnormal, and that depends on our own culture and judgments of normality.
Unfortunately, we in healthcare think of ourselves as idealized, a neutral and scientific discipline that makes sense of people and their individual psychopathologies (not the best word), their individual experiences. But people live in a society that has treated them badly, they had adversity in childhood, are poor, and live in unsafe places. They’ve had generations of trauma and mistreatment.
You know, there are marked disparities in coercive care, detention, and criminalization of black patients; there’s over-detention of black patients. There is much written on the relationship between criminalization, the criminal justice system, and the psychiatric system for a hundred years, that the two are connected.
I’m painting a more complex picture than most clinicians, regulatory systems, or governance systems have tolerance for. Everything’s bureaucratized to something simple, straightforward, and measurable. We’re going through mental health reformations to be implemented, but the Mental Health Act, like all legislation, is designed such that compliance with the act becomes more important than providing care to the patient and listening to what the person wants.
When we’ve got a fragmented or impoverished care system, the bit that gets resourced is the legislation—locking people up and detaining them. This might explain why our rates of detention have been going up and could also explain why our prison populations are escalating.
Dhar: You mentioned language. The words that a patient uses open up certain avenues of understanding and close others. For example, in English, when it comes to addiction, there is emphasis on identity—you are an alcoholic—and for recovery to have to take up that identity. But in Hindi, people say, “Woh pita zyada hai” – he who drinks too much. It’s an act. There is a distance between who I am and the harmful act I currently commit, and that space allows me to change my behavior. In a similar vein, could you share an example or maybe a case where culture, context, and class define people’s idea of what is even problematic or unusual?
Bhui: Let’s take hearing voices. We know that hearing voices is common; up to 17-20% of people transitorily hear voices. Now, they don’t have a mental illness. Obviously, those who hear voices in a sustained way, and if it also leads to a deterioration in functionality and ability to attend to their environment, then it comes closer to something called illness. But the hearing voices alone isn’t enough.
Assessments of mental health problems are full of all these different behaviors, beliefs, and acts that might be considered unusual, and your point about categories is well made. We categorize based on how bad an experience is, how problematic it is, and once we label someone as psychotic, that becomes the dominant identity. We put them in a position of being observed, and by doing that, we’ve already removed some power. It’s what I’m hearing from your example—some autonomy and agency are left in them. But when you say someone has schizophrenia or they’re schizophrenic, it’s a power relationship. You’ve asserted a particular category as opposed to the understanding that they are a person currently with these symptoms and might do better later.
You might consider them unusual if you don’t take into account their health beliefs, levels of hallucinations, and what people in their peer group think. We know hearing voices also happens in acute distress, in stressful situations, which has nothing to do with long-term psychosis. So, this one symptom, to some people, represents pathology and abnormality, but it can be present in so many different ways. How do you distinguish when it’s unusual? It’s by knowing more about the person, how it fits into their life, and to what extent it’s unusual for them.
Similarly, with beliefs that are called delusional. If you believe in supernatural forces and the Gods acting on you, that isn’t necessarily unusual, but if it means that you are unable to function, can’t get out of bed, or are terrified about what’s going to happen, then that starts to change the meaning of that belief.
Cultural competency is important, but it’s also become a problem—people think the solution is simply learning about someone’s culture, their foods, festivals, or knowing which ethnic group they belong to, as if that tells you anything about them. Cultural competency has been bureaucratized and simplified to online 30-minute MCQs, rather than the more complex task of taking time exploring people’s beliefs, relating to them, and experiencing what they experience.
As a psychiatric psychotherapist, we make ourselves very sensitive to the other person’s internal world, and use ourselves as a barometer in that process. That’s the bit of care, clinical practice, and training that has gotten diminished. The field of cultural psychiatry and notions of cultural competency are always paid lip service in training, and I’ve heard and seen them ignored or simply dismissed as unhelpful or a waste of money.
We’re working in a time-pressured, bureaucratized algorithmic process. So, my advice to most trainees and clinicians is you have to take time, but that’s only possible if the systems let you spend time with people, to allow for translation and interpretation. Words are so important. If you misunderstand a word and pathologize it, that could affect someone’s ability to look after their child, or lead to being admitted to the hospital.
Our research shows that people’s own experiences and the ways they communicate them are not heard and valued. Only their illness narrative or their patient identity dominates. The person listening tends to negate what they’re hearing. The clinicians were saying, “We don’t believe you, you should go away, or we’re too busy, come back later”. People were saying, “No, I really need help now”. They knew that if they didn’t get it, they would be detained, which ultimately happened.
Dhar: We talk a lot about individual practitioners and the compassion that they should show, but I remember Helen Spandler’s work on how to develop compassionate systems. It’s not just about compassionate practitioners; it’s about developing systems that have compassion in them. You talked about the importance of the clients’ own beliefs about their suffering. This is Kleinman’s work on explanatory frameworks – clients’ own stories of distress that are informed by their individual experiences, life history, culture, and context, such as class. These are their own stories of why they’re suffering, and what would help. You write about cherishing these stories. What has been your experience of working with patients and their own explanatory models, and how do you work with them?
Bhui: Assessing people’s beliefs and explanatory models is essential, but not many do it. It’s important for two reasons. Firstly, to fully understand what they’re experiencing and what sense they make of it, before you start proposing solutions. If you don’t, the solutions will be ill-fitting. They won’t fit their explanatory model or their expectations; people will be disappointed, and less likely to engage in what you’re proposing.
The other important component is understanding an alternative belief system. If there was a match between belief systems, or an attempt to reconcile beliefs before starting a treatment plan, or support for someone choosing not to do something, that would help the therapeutic alliance. That would allow people to trust and engage in a process. It would be hopeful, fulfilling, and optimistic because it aligns with what they already believe, rather than giving them psychoeducation or telling them to ignore their belief system just because you hold the authority of a title and qualification. That doesn’t work.
But very rarely do those beliefs get reconciled in practice. A colleague of mine found that most of the time, people’s painful stories go unheard. So, I’ve switched my way of working to start by listening to the story people are bringing and taking a more biographical account. This used to be a part of good psychiatric practice when I got trained. But over the years, the time has been squeezed. There are digital checkboxes to tick, and the interpersonal connections begin to diminish.
The systems that we have don’t work, and the answers to what might work lie in the stories that people hold about their lives, and I call it experience data. It’s knowledge. But we don’t give it enough attention in routine practice or policy making. There is a movement in the UK to involve lived experience experts in research, policy, and practice. But to do it really well, there has to be time. People have to be remunerated. Unfortunately, our non-compassionate systems tend to squeeze out the opportunities to gather those explanatory models and understand better.
Diagnosis is just a guiding principle. It’s a shorthand for something we think might be going on, but it doesn’t tell you much about what the person’s life is like and what might be helpful to them. It is mandated in some places as a quality measure, or, if you haven’t got a diagnosis, the commissioner won’t pay for the service. The systems are pushing us towards a bureaucratic practice rather than a therapeutic practice.
We know diagnosis is a theory that’s been over-exported as having scientific validity, but we’re talking about reliability, not validity. It doesn’t really tell you what sort of support and care someone needs; people with the same diagnosis might require quite different things. It is fiction, creating a diagnosis. It might be useful fiction for the commissioners and for the service, but you end up having three or four diagnoses.
Having said that, the other side to the story is that some people, when they’re given a diagnosis and they spent years not getting one, find that very reassuring – “Oh, you know what, I looked this up on the internet and it makes sense”. For the first time, they don’t think they’re odd. They think, “I now understand myself better”. Diagnosis can help the person make sense. We haven’t really understood whether making a diagnosis helps or doesn’t help in terms of people’s personal empowerment and recovery.
We have become less effective as carers, healers, supporters, and advocates because of the systems in which we’re operating. To change the system, you have to change the minds of politicians, the public, and social attitudes towards health and illness, and also stigma. Migrants and ethnic minorities are on the receiving end of a lot of hostile policies in many countries, with the extreme right rising. This causes direct problems for their health and well-being, and also makes it harder to access policies that support them.
Dhar: Diagnosis can absolutely do both. I’m thinking about Rose Cartwright’s book, The Maps We Carry, and she gives a first-person experience of being diagnosed with OCD. Her first book was about the relief that brought. Her second book was about being trapped in that identity and having to crawl her way out of it. It can absolutely do both.
You write that exploring a client’s own narratives requires careful observation and open-ended questions—“This embraces the authentic view of the patient’s world. This is lost if the questions focus on making a diagnosis and introducing a treatment”. In effect, you critique the singular concern we have with making a diagnosis and determining treatment. What happens when the singular focus of the clinician is on making a diagnosis? And I’m not just talking about what the patients lose, but also what clinicians lose when that is all we’re told to care about?
Bhui: Yeah, that’s a really important question. What do clinicians lose? And we don’t often think about that, do we? Actually, it’s a pretty unrewarding experience to see people, quickly diagnose them, propose some treatments, and refer them elsewhere. What gets lost is the authentic experience of understanding, hearing, listening, and engagement. The sense that someone is listening to you and understanding you is rare.
As a clinician, you feel like an instrument of the state or of the system, which is not compassionate or caring. The diagnosis might not be correct if it lacks context for their socio-cultural lives and heritage. They might be prescribed something that is algorithmically correct, follows a guideline, but doesn’t really reflect their personalized needs. It might not fit their own decision about what they would like.
We forget how painful it is to share difficult feelings and experiences and how much courage and trust it takes. People leave feeling invalidated. Many studies with young people find that sometimes seeking help is worse than not bothering because they feel invalidated, and it compounds their sense of alienation, isolation, and lack of confidence. In fact, they see it as another adverse experience, as traumatic as something horrible that’s happened to them in the past. They sought help, and someone diminished their views. Everyone loses. Many people leave the UK public sector and go private. Their reasons often aren’t that it pays better; it’s actually that they can do a better job, spend more time with someone, and understand them.
Dhar: So, a couple of things. One was your significant amount of work around ethnic minorities in the UK, and the fact that they face higher rates of forced institutionalization and coercive treatment. In the UK and Canada, studies have repeatedly found that immigrants, especially those who look and talk differently, show much higher rates of psychosis and schizophrenia.
On one hand, we know social disadvantage, such as poverty and discrimination, definitely contributes to higher rates of psychosis. But there were two bits of research that were interesting. One study found that the risk of psychosis in immigrants immediately goes down if they live in areas where there are other people from the same area of origin, people who look, talk, think, feel, and hurt like you. The second study talked about something called ontological insecurity. This is Laing’s concept—a sense of unstable self, alienation from the world, feeling that everything is unreal, existential unreality was more related to psychosis than childhood trauma or even attachment issues.
Since you’ve done so much work on this, what do you think is the causal link between people from certain geographical regions showing higher rates of schizophrenia and psychosis in the UK?
Bhui: Yes, individually, a form of distress we know is to hear voices and develop this thing called psychosis. Hearing voices is common, and higher in urban areas, in minorities, and in populations that have been traumatized.
You are referring to the ethnic density hypothesis, which holds that people of a similar heritage or background to you in the locality could mitigate the risks—there is support for this. You don’t feel so isolated or alien. Plus, it might literally reduce the risk of discrimination and marked racism towards you. But it may also raise concerns about conformity to group or cultural norms.
And then living in low-ethnic-density areas. The evidence is that minorities of a high socioeconomic status go to low ethnic density areas. That is linked with a larger risk. I guess we still don’t fully understand the mechanisms. But your broader question about geography is really interesting. Back in medical school, I made a map looking at the rates of schizophrenia in different parts of the borough of Southwark in South London.
I do think mental health problems are definitely linked to place. Place is important because some places are ultra-deprived, and some places are unsafe. There might be gangs, criminality, and poor housing. If you grow up or live in a place with multiple types of disadvantages and adversity, and you have a vulnerability, you’re more likely to end up with a psychosis.
There are two theories I have moved towards beyond the biopsychosocial one. One is called syndemic theory, which is very place-based—this combination of problems is almost inevitable in some places where there’s lots of adversity in the environment. The other is the eco-social approach—thinking about a wider system, the individual living in a family, on a street, in a locality, in a town, within a region, within a broader society. We see that mental illness is something that happens at critical periods early on in life. And I think living in a place where you’re not protected or cared for, you haven’t got parental figures or carers, it all leads to it.
Actually, there are some biomarkers they’re beginning to look at, like inflammation. It doesn’t mean that the environment isn’t important. The environment drives inflammation and might be driving rates of depression and mental illness. If you live in an inflammogenic environment full of trauma and adversity, you’re going to be more vulnerable. It speaks to improving the places we live in, more green space, safer places, and better housing. Better protections from air pollution, noise, and crime all help young people develop safely and flourish. It’s so interesting what you said. The place issue is a contemporary problem that we need to tackle for the future. That’s relevant to policy in the UK, where we’re increasingly looking to improve health in neighborhoods locally, rather than having a national body say this is what we’re going to do everywhere.
Dhar: I’m interested in how, on one hand, we see vulnerability paradox, which is that countries with more wealth, stability, and healthcare also report more PTSD, and on the other hand, we have research saying that adversity and unsafe neighborhoods all cause mental health issues. What could be happening here?
Bhui: It is a question of our time. Isn’t it? We worry about treating mental illness, so we stand by and watch war and trauma in the world and don’t do anything about it. When you’re in the conflict zone, you have to survive emotionally and psychologically, so you’re defended. You may not experience anxiety and distress in the same sort of way. You have loss events, and that will be traumatic, but it’s usually later, when you are safe, or there’s a mourning process that you begin to feel the ghosts from the past.
There is a solution. It is not just about health professionals. It’s also about society and the social efforts of organized society. Of course, we need to stop war and trauma, but we also need to address both commercial and political determinants. Sometimes our politicians add to the problem. Hostile policies, which are built on stigma and are fundamentally racist, aren’t really policies.
As clinicians and policy advisors, when we work with the government, it’s their decision, but we give the evidence. Normally, they listen to the evidence, scrutinize it, argue with us, knock it out, and come up with a better idea. But now that’s not happening, and it’s a non-reconciled process through which actions are being taken in the name of evidence, and we’re at a very dangerous time in many ways.
Dhar: You’ve experienced misidentification, discrimination, violence, and navigated multiple identities, and it seems to have informed what you study. You wrote that early in your practice, you saw that much of what you had learned was limited, especially when it came to the treatment of minorities. But other psychiatrists often didn’t see these issues.
I have two questions here. One, what did you notice being done that was either irrelevant to this group or even harmful? Two, when you brought it up, what was the response of those around you?
Bhui: Growing up as a migrant in the UK—at one level, we had a good upbringing, reasonable schools, but we lived in a very poor area, and we were one of the very few minorities there. Racism was around us. But when I became a doctor, I wasn’t thinking about that; I was being a “good doctor”, a “good psychiatrist”, doing what the manual said.
I was fortunate to come across cultural psychiatry. I observed that when there were presentations of a black man with psychosis, it was assumed he had a cannabis psychosis; cannabis psychosis was seen as cultural. I noticed people receiving a diagnosis of schizophrenia, but often they just seemed to be destitute, homeless, and in need of welfare support and housing. It is possible they had both, but none of the obvious symptoms of schizophrenia were present.
I saw the walls increasingly filling with black men, and no one was noticing it. I observed people were very unwell physically and not being cared for. I’ve seen higher incidence rates of psychosis and disparities in coercive care and use of involuntary treatment in minorities. It was considered necessary and not a function of our systems of criminalisation and structural barriers. There is also diagnostic bias; for example, more mania or mood symptoms are recorded as schizophrenia among ethnic minorities.
I thought, why is no one noticing and responding to this? There is hostility towards reducing ethnic disparities, or admitting to the existence of structural violence or institutional racism, from senior clinicians and politicians leading whole programmes of reform. In the early years, I was not sure if what I was observing was a mistake or simply good practice that I had to learn; later, especially with the work of Roland Littlewood and Maurice Lipsedge, and Suman Fernando, I was sure this was a culturally blind and hostile system and the cost was met by patients.
My research efforts have assumed a rational process of presenting evidence, yet this, too, has always been challenged or dismissed in favor of easy institutional responses. I just knew it didn’t seem right that so many people were being detained, had been boarded.
Dhar: My last question for you is about your new book, which is a young-adult novel. It’s called The Maharaja’s Bodyguard. Tell us a little about it.
Bhui: Thank you for asking about it. I had been interested in writing for a long time I had boxes full of bits of writing that never went anywhere. The book is a dual time fantasy of a young boy growing up in the 1960s in Britain, who is transported back to the times of the Raj and becomes a warrior. So, he’s bullied and harassed in Britain and then finds his courage and strength from his ancestors. His identity comes back with magical powers, and the two sort of fuse.
It’s playful, but some of the themes are quite serious around distress and insanity, and how people cope with it. But creating a fantasy version of it was helpful. My work with creative arts and mental health shows that creativity and things of beauty enable people to hear messages that they can’t otherwise hear, which might be troubling or traumatic. This fantasy also and the creativity softened the pain of some of the experiences.
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