We are going to talk about Us and Them and talk about psychosis among ethnic minorities. I want to start with some very basic observations about what it is like to be human. Humans are confronted with being in a world with a lot of other people around them and we have some basic needs in order to deal with that. Very basically, we all need to belong, we have to be connected to other people, we need that to thrive, to live and to prosper. We need to be accepted and to be valued by other people and if we are not then we are in trouble. The funny things is, we always try to make groups.
This is a picture (PowerPoint) taken in Tilburg during Red Hair Day which shows a large group of redheads. People try and find people who are similar to themselves, they want to make groups. We want to make groups, we need that, we need to belong and we make categorisations. That’s all O.K. and funny and good but we tend to make groups along the lines that create some problems because a lot of groups that we create are along the lines of ethnicity, culture or religion. That’s when the problems start because we tend to see ourselves as better than others, that our groups are superior to other groups. Then there are confrontations and problems arise and that can actually be quite extreme. In recent history there are ample examples showing that things really go wrong because of our tendency to make groups and to feel better than others. If you want to read more then there is the classic novel “Lord of the Flies” where you see that the young boys start in a really innocent way and it ends in tragedy.
For me one of the most vivid and horrifying examples is the story of Rwanda, a book you really should read called “Shake hands with the Devil”. Here you can see how the creation of ethnic groups such as the Hutus and Tutsis created this genocide. We are not aware that there is this Us and Them rooted in our history and our tragedy is usually much more subtle. When we make groups along social lines, social status, social comparisons, then it’s not about killing each other but about comparing ourselves too each other and we want to have a slightly higher status than other people. There is actually a lot of research showing that these differences in social status make a difference in health, in illness and in life expectancy. The big thing is not the actual absolute wealth you have or the things you own but the comparison. So, if you are lower in social status than the people around you then you don’t have control over what’s going on in your life and you feel that there is a lot of inequality as a consequence your health will be worse than that of other people.
Michael Marmot, a famous epidemiologist from the U.K. wrote a book called the Status Syndrome and Richard Wilkinson and Kate Pickett have written “The Spirit Level”, it’s about inequality and includes many examples showing that this relative inequality within a country, a city or within a social group actually creates differences in health. Why am I telling you this when I’m supposed to be talking about psychosis in ethnic minorities? This introduction is needed because it shapes the way we look at this problem and I will demonstrate why this is relevant for psychosis in ethnic minorities. A few months ago, Jean Paul Selten published a new meta-analysis about migration and psychosis. Over and over again studies from Europe show that people who migrate from all kinds of different countries to Europe have a greater risk of developing a psychotic disorder. On average the risk is increased twofold but there are some differences. People who have a coloured skin have a much higher risk of psychosis than migrants with a white skin when migrating to predominantly white countries. It is not only people who migrate that have a higher risk but also their children, their offspring. The second generation also has an increased risk of psychosis. What’s going on here? How can we understand this?
Here’s an example of our work here in the Netherlands. We did our first contact incidence study on psychotic disorders in the Hague a couple of years ago. In the Netherlands we have 4 large migrant groups (ethnic minority groups): Morocco, Surinam, Turkey and the Antilles. These 4 groups are mostly represented in the Netherlands in the bigger cities in the Western part of the country. We did a 7-year first contact incidence study and this was our puzzle. We found that both first and second generation have a higher risk for psychotic disorder but not all groups have the same risk. People from Morocco for example have the highest risk of all, especially young Moroccan men have around a 5 times higher risk of psychosis. It’s not only migrants but it’s also their children, the second generation who have an increased risk. We are not the first with these findings (the first observations were carried out as long ago as the 1930’s) and there is a lot of debate about how to interpret these epidemiological findings. Many researchers have argued that the results are not accurate, that there is some cross-cultural misunderstanding.
There are lots of reasons why you can end up with these facts and figures, maybe there is a higher incidence of psychosis in the country of origin anyway or maybe it’s because of selective migration. It could be that people who have a vulnerability to psychosis are the people who will more often migrate. Maybe people like myself, a white psychiatrist, perhaps I don’t understand these people with their different cultures who present themselves in a different way that I see as psychotic but may be culturally completely appropriate. Or worse, maybe there is constitutional racism going on. Because of the Western health-care system in psychiatry, our own prejudices and our racist views about migrants might lead us to make a diagnosis of psychosis. On the other hand, if you look at the literature then you realise that it’s becoming increasingly more accepted that there is some important link between migration and ethnic minority status on the one hand and psychosis risk on the other hand.
More and more the idea is that this has more to do with social context in which people live, that it’s about social cultural factors, that it’s about social defeat which is about people who are in circumstances in which they feel defeated by their social context. Maybe it also has to do with social adversity, economic status and general problems. There are also a few biological explanations, a low level of vitamin D for example. There are a lot of possible explanations for these findings and I’ll talk a little bit about the social hypothesis, the social cultural factors. If you want to understand epidemiological patterns and rates of illness you have to take into account that an individual is part of a larger context. A person is part of a family, a person is part of a social cultural group, a person lives somewhere, a neighbourhood, a person lives in a society, in a country. All these levels influence experiences of the world and how you deal with it, how you respond to illness and health. If we want to understand these increased rates we have to take into account all these different levels of influence. So, what is this ethnic minority context that were talking about?
We have done some studies on these different levels and one of the things that we investigated was something that’s called ethnic density. Here is a picture of London (PowerPoint picture) showing where people from different ethnic groups live. You see immediately that the ethnic groups are not distributed equally throughout the city, there is a different proportion of ethnic minorities in different neighbourhoods. We studied this phenomenon in the Hague and here we saw the neighbourhoods in the Hague where we did this incidence study which showed the distribution of ethnic minorities in the city. You can see quite a lot of differences between the two studies. Here there are two neighbourhoods which have a really high proportion of ethnic minorities, we call that “high ethnic density” and the rest of the city had a much lower proportion of ethnic minorities. We studied the relationship between this ethnic density and the incidence of psychotic disorders. We found that the rates of psychosis were much higher in neighbourhoods where there was a low ethnic density, where people were living relatively alone, compared to the high ethnic density areas.
Remember this was a comparison with the native majority population and you can see that the incidence rates were significantly increased only in neighbourhoods with a low ethnic density. You can also see differences between different ethnic groups, the Moroccan group stood out so you see that this group seems to be vulnerable to something like ethnic density. Again, you can ask, “what is the meaning of this”? That’s always the problem in epidemiology you’re fighting against “what does it mean, what’s behind those numbers?” So, what happens when you’re a minority in the neighbourhood where you live? How do you feel? How do you respond? An important conclusion is that it’s not low socio-economic status, that’s not the explanation for this because the neighbourhoods with the high ethnic density are the poorest with a lot of socio-economic problems. There is something going on that actually buffers the disadvantaged neighbourhoods, something that is stronger than the socio-economic influences, what’s happening? It looks as if it has something to do with exposure to discrimination, maybe it has to do with experiences of social exclusion, or isolation, because when you’re alone you don’t belong. I found a picture online it showed a banner saying “No Jihad on the street” which means we don’t want them in our backyard, in our neighbourhood. If there is a majority response like this towards you every day then it probably makes you feel bad. So, what we did was to relate the incidence of psychosis to the degree that ethnic minority groups perceived this discrimination in the Netherlands. We had rates of discrimination divided by an ethnic group and related that to the incidence of psychosis. We found that the more an ethnic group perceived discrimination, the higher the risk of psychotic disorders in the Hague. It looks as if these social experiences really shape the pattern of the rates of psychosis.
Of course, there is a lot of literature showing that perceived discrimination has an adverse effect on mental and physical health and actually affects everything. One of the mechanisms might be that perceived discrimination leads to a heightened stress response which in turn leads to poor mental and physical health. You also see that there are some things that may actually buffer this effect, such as social support, stigma identification and coping styles. That relates to the ethnic density part because if there are many people like you then maybe that can buffer these experiences of perceived discrimination. We wanted to know, when you are in the minority and you feel discriminated against whether, at the very least, it’s a threat to your identity. It gives you a lot of stress so how do you respond when confronted with such an environment when you live there? Broadly speaking you can choose one of two strategies to deal with this, one is that you can try and join the majority group, the other strategy is that you can actually stress your identity and be proud. Black is beautiful was a movement in the 1960’s in the U.S. “we don’t feel ashamed, it’s great to be black, we’re special”. So those two strategies may actually help in adverse circumstances.
This is an example of a Moroccan-Dutch man Nasrdin Dchar, he is a Moroccan-Dutch actor who actually won the Dutch equivalent of the Golden Globe for his performance in a film. When he received this prize he made a statement, he said “I am a Dutchman. I am very proud of my Moroccan blood. I am a Muslim. And I have a f** Golden Globe in my hand!” So he said “I’m proud of being Dutch and I’m proud of being Moroccan” A few months later he posed for a picture showing both these aspects. This is actually a difficult thing to do because it’s quite difficult to combine these identities, to be strong and to develop a positive identity. We investigated this in a case control study on schizophrenia. These two strategies: The first one, trying to join the majority, is quite difficult when you are a quite visible minority and people reject your group. The second strategy (Black is Beautiful) has been proven to be successful and is related to very positive health outcomes. The case study went on to interview 100 schizophrenia cases from ethnic minorities and 100 “healthy” controls and asked them about acculturation and their ethnic identity. We found that the risk for schizophrenia was related to their strategies. Assimilation for example was associated with the highest risk for schizophrenia whereas separation as a strategy was protective. What does this mean? Separation is that your identity is predominantly ethnic, you are proud of being Moroccan, Turkish etc. Assimilation means you want to be Dutch and to forget a bit about your ethnic background, you want to join the majority.
So you can see here the same pattern and the way people respond to this identity threat and to this adverse social context. Later we thought that we needed to investigate younger people who don’t yet have a psychosis and see if we could prevent that. So, we talked about psychotic experiences, that’s not clear psychosis but these are some clinical experiences of psychosis we investigated. We asked 1800 of those people in schools about their ethnic identity and we saw that again separation had the lowest reference of psychotic experiences. Assimilation was raised to a higher level. Marginalisation, if you don’t have an identity at all, was seen to be the highest risk. Again, we found there was an association with perceived discrimination. Similarly, the work of Anglin’s group shows once again the interaction between ethnic identity and discrimination, the outcome in this case was psychotic experiences. People with a strong ethnic identity, when confronted with discrimination, have a lower rate of psychotic experiences than people with a weak ethnic identity. The same pattern over and over again.
So you see that on these different levels, on an individual level, you need to deal with the social context in which you live in, the neighbourhood you live in, the society and ethnic group that you live in, it’s all related to the risk of psychosis. So, it is about “Us and Them” , about how we categorise people, how we relate to other groups and how we deal with social adversity. The big question is, what can we do about it? We are only human, we can’t stop categorising, we can’t stop feeling better than others, so what can we do? It’s a difficult question, a lot of this research has been done 10 or more years ago and still the problem remains. The big question is how can we reduce this Us and Them? How can we increase the Us part and reduce the Them part? Based on the findings we have I think that a lot of things can be thought of. We need to help people growing up in an ethnic minority context to build up their identity and discover role models, how to connect with communities in order to help them to build a strong identity. The “Black is Beautiful” idea, how can you help people do that? Also, we need to teach people that there is more than just ethnicity, they can introduce at least 10 different parts of their own identity. You are for example not only a Moroccan-Dutch boy you’re also a soccer player, you’re also a good student, you’re also a brother or a friend. You have many identities so use them and be flexible wherever you are, at school, with your friends or on the streets, use the different parts of your identity. How do you do that? It’s quite complicated. However, most people do it every day, for example, you behave differently at this convention than you do at home. We have to train young people to do that. On the other hand, we have to address all the other levels, the neighbourhoods, society, the families. We have to keep fighting racism and we have to try and increase equality and in order to do this we need politics, we need communities, we need neighbours. We have to create social capital. How can you connect? If you find that you have things in common with people from other groups then you create this Us again and prejudice and inequality and racism will disappear.
We did a MasterMind study amongst the adolescents I mentioned earlier, to try and see whether we could do something like this. Can we actually help young children by building this trial entity? We did a screening study for two years in a row and we screened children who were 12 years old to see who was high-risk for psychiatric problems and anxiety for example. The children that were seen to be high-risk two years in a row were invited to take part in identity training. It was a multi-ethnical group because we were convinced that it is not only about ethnic minorities but also about culture and we all have to learn to build a strong identity. It’s not all about ethnicity. We gave an 8-week, group-based training to help children to build their identity and to empower them and also to train away the negative things they were focussed on. During the observation period the psychotic experiences remained the same and after the training they decreased a little and later they decreased even more. This is a first attempt to actually help a child become a strong person and to try and prevent all sorts of psychiatric problems, their self-esteem went up and the risk of psychiatric disorders went down. So, you see it is possible.
To end my talk, I’ll give a few examples: There is an important mechanism and it’s called the stereotype threat. When we see people from other groups we immediately have all kinds of ideas about these people that we may not even be aware of. Claude Steele, a psychologist from the U.S. wrote a book it’s called “Whistling Vivaldi”, it’s about a man who says “Every time I’m walking on the street in the dark and white people are walking there and they see me, they always look scared, they cross the street, they go away and I’m sick and tired of that because it’s just me! I’m not dangerous, I’m not a criminal”. He discovered that when he saw white people approaching and he whistled some notes from Vivaldi, he saw those white people think “It’s o.k. he’s one of us”. It’s a funny story but try to understand the actual meaning of it because you can break stereotypes, you can connect. Sometimes this can be in a very simple way, remember that. The second example illustrates that we have to keep telling stories: This summer I read a book called “The Nickel Boys” by Colson Whitehead. It’s a story about boys in a school where they ended up and everything was very unjust. They were tortured and they had no future. We have to keep telling children the stories about racism, about inequality and about injustice because in the end I am convinced that it helps. It may take a long time but it will help.
My last example is an award-winning book which has now been made into a film “The Hate You Give”. It’s a quote from Tupac and I remember working in the Hague 10 years ago and all my patients, boys with psychosis, their favourite music was Tupac. He’s talking about the hate you give and he said the hate you give to your children f** s up the next generation. Our responsibility is not to f** up and not to say “well there are these groups and this hate will always be there” but please keep trying to change things. It may seem impossible and it may take generations but change is possible. For me that’s very inspiring and I think we are all working along these kinds of lines so I encourage you to please keep doing the good work that you are doing because in the end it will make a change.
So it’s “Us and them and after all we’re only ordinary men” (Pink Floyd).